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Red-State Voters Take Medicaid Expansion Into Their Own Hands

The midterms will feature four ballot initiatives in Republican territory.

Scott Olson/Getty Images

Nebraska may be one of the most conservative states in the country, but in November, the state’s voters could advance a liberal cause. On Friday, Nebraska Secretary of State John Gale confirmed that organizers had collected enough signatures to put Medicaid expansion on the general election ballot this fall, making it the fourth state to do so this year. Voters in Utah and Idaho will also consider an expansion in November, and Montana voters will decide whether to make permanent the state’s current expansion, which is due to expire next year. If it passes, the initiative would extend Medicaid to an estimated 90,000 low-income Nebraskans.

Montana, Utah, Idaho, and Nebraska are all reliably Republican states, while Medicaid expansion, which is optional for states, is the product of Barack Obama’s Affordable Care Act. Thirty-two states, plus the District of Columbia, have opted in; Virginia is the latest state to do so, after several Republican legislators defected and joined Democrats to pass expansion. But even these red-state voters seem open to the growth of government-subsidized health care—Medicaid is jointly funded by the federal government and individual states—and polling suggests they just might endorse it. A June poll put Utahns’ support for expansion at 63 percent. In Idaho, a June poll found 66 percent support in favor.

These polls, if accurate, depict a voting population at odds with their states’ Republican legislative majorities. In each state, voters are preparing to sidestep officials who have either blocked Medicaid expansion entirely or passed it with significant restrictions. They therefore follow a pattern first established by voters in Maine, who passed Medicaid expansion by referendum in 2017 after the state’s Republican governor, Paul LePage, repeatedly vetoed expansion bills. The Maine Supreme Judicial Court ruled last Thursday that LePage must implement the expansion his voters approved.

Similarly, Republican legislators in Idaho blocked a limited expansion proposal. In Montana and Utah, legislators passed versions of expansion that either didn’t make access permanent, or restricted access to a small population of beneficiaries. Utah’s version of expansion, for example, includes a work requirement, and as Vox reported at the time, it only extended Medicaid access to households making “up to 100 percent of the federal poverty level.” That’s much more restrictive than the Affordable Care Act, which says states can expand access to households making up to 133 percent of the federal poverty level. Utah voters will pass or reject an expansion proposal that increases that minimum income requirement to 138 percent.

“These ballot initiatives are sort of a major breakthrough in the campaign to expand Medicaid in every state,” said Jonathan Schleifer, the executive director of the Fairness Project, a national organization that describes itself as a “key player” in passing Medicaid expansion in Maine. “We found a new strategy for expanding Medicaid in states where politicians don’t want to—and it’s by going over their heads and straight to voters.” The organization put about $1 million into the Nebraska campaign, which is being led by the Insure the Good Life coalition, and has invested nearly $5 million on Medicaid expansion campaigns overall since its first election cycle in 2016.

Successful efforts to get Medicaid expansion on state ballots tend to complicate the narrative about conservative states. “‘Deep red’ Idaho is peopled with pockets of deep conservatism, but it’s no monolith: Trump won only 60% of the vote in Bonneville County, for example, in part because 20% of the vote went to anti-Trump, Mormon independent Evan McMullin,” Anne Helen Petersen recently explained in a BuzzFeed piece on Reclaim Idaho. (Reclaim Idaho toured the state to get enough signatures to put Medicaid on the ballot, and organizers are back on the bus now, marshalling public support ahead of November’s vote.)

Missouri voters exhibited a similar dynamic in August, when they emphatically overturned a right-to-work law supported by the state’s former Republican governor, Eric Greitens. Public referendums don’t always guarantee victories for liberal causes; in 2016, Nebraska voters reversed the state legislature’s repeal of the death penalty. But it seems increasingly clear that policies widely considered liberal or Democratic—by commentators and politicians alike—can still garner bipartisan support from voters.

“I think we’ve seen the movement to expand and protect health care is one of the most powerful forces in American politics today,” Schleifer said. “If the last year has told us anything, it’s that Americans want more and not less health care and they’re willing to fight for it, whether it’s in town halls or by getting arrested outside their senators’ offices or waiting for [Maine Senator] Susan Collins at the airport to let her know what they think.”

But as the example of Maine warns, Medicaid expansion may encounter stiff opposition from state Republicans, even if voters approve the provisions on their ballots. In Nebraska, a current Republican state legislator and a former Republican state legislator have filed suit to block Medicaid expansion from officially going on November’s ballot. “They argue, among other things, that the expansion proposal contains more than one subject, is in violation of the Nebraska Constitution and does not properly disclose the Nebraska Appleseed Center for Law in the Public Interest as a petition sponsor,” the Omaha World-Herald reported.

Like their peers in Maine, Nebraska voters also have a Republican governor, Pete Ricketts, who is hostile to Medicaid expansion. In a column published on his official website, Ricketts claimed that expanding Medicaid “would be an expensive burden for Nebraska taxpayers, adding an additional $158 million burden to the state budget and competing with other budget priorities like meaningful property tax relief or future roads funding.”

It’s not clear, however, if Ricketts will go as far as LePage and launch a futile legal battle in the state’s courts to halt or at least slow the expansion the process. LePage is constitutionally barred from seeking another term in office, but Ricketts is up for re-election. And if successful campaigns to put Medicaid expansion on state ballots prove anything so far, it’s that big government is maybe more popular than Republicans have allowed.