Medicaid Expansions Come Down to Voters vs. Legislators

By FOCUS, a Leonine Business

Medicaid expansion has been one of the hottest topics in state legislatures for nearly a decade now, following a 2012 Supreme Court decision which, among several other key provisions, ruled that the Medicaid expansion provisions of the Affordable Care Act were opt-in only, meaning that individual states themselves could choose whether to expand the program or not. The main method for adoption in most states has been the legislative process.

Predictably, the issue immediately went partisan – blue states adopted the expansion almost immediately, some purple states lingered, while many red state legislatures are still holding out against it. While the expansion has not been popular among lawmakers in these states, it has remained immensely popular among the general public, even in states that have not implemented it.

Heading into 2020, 36 states and the District of Columbia have accepted the expansion, most through the traditional legislative process. Fourteen states have so far refused to expand the program – Alabama, Florida, Georgia, Kansas, Mississippi, Missouri, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Wisconsin and Wyoming.

Following years of inaction on the issue, Maine expanded the program in 2017 through ballot initiative. Citizens in other non-implementing states quickly took notice and organized to do the same. In 2018, Idaho, Nebraska and Utah voters all passed ballot measures to expand Medicaid, much to the ire of their own state representatives. But the state legislatures in these deep red states struck back.

Legislative alteration” is a newly coined phrase describing when a state legislature modifies the terms of a law enacted through the ballot initiative process. Several states have restrictions on legislative alteration, but 11 have no restrictions, meaning legislators can amend citizen approved laws with a simple majority vote. Seven others require a supermajority vote, while California requires voter approval to amend such a law. While many see the practice as inherently un-democratic, some state lawmakers see it as their prerogative. It has taken center stage in the debates over Medicaid expansion, as state lawmakers have used the tactic to modify the terms and conditions of the voter approved expansions.

In Idaho, state lawmakers passed SB 1204 in the session just after the expansion was approved, which places work requirements on the program. The initiative, as passed by voters, contained no work requirement language. Utah lawmakers straight-up repealed the voter approved Medicaid expansion and implemented an alternative expansion under their own terms, which included eligibility changes, work requirements and an enrollment cap.

In 2020, Medicaid expansion will be on the ballot in Mississippi, Missouri, Oklahoma and South Dakota. Florida may also see the issue on the ballot in 2022, and groups in other holdouts are working to get the issue on the ballot as well. Polls have shown that both Democrats and Independents view health care as their top issue; for Republicans, it is second behind immigration.

State lawmakers, especially in red states, will need to keep in mind the popularity of Medicaid expansion and health care cost containment generally. As health care costs continue to rise, voters will show their displeasure with inaction at the polls. State lawmakers have an excellent chance to act during the 2020 legislative sessions – it remains to be seen whether they will squander this golden opportunity.