While not typically an election issue, Medicaid — particularly the Medicaid expansion created under the Affordable Care Act (ACA) — was an important issue in the 2018 midterm elections in a number of campaigns throughout the country. Following the election, 37 states including the District of Columbia have adopted the ACA’s Medicaid expansion. States may implement the expansion at any time, and while they can no longer receive 100% federal financing for three years, they remain eligible for enhanced federal financing of 93% in 2019 and 90% in 2020 and beyond. Many studies on the effects of the ACA Medicaid expansion point to positive effects on coverage, access to care, service utilization, and state budgets and economies. This fact sheet highlights key states in which the results of the 2018 midterm elections have implications for Medicaid expansion adoption or implementation. States examined include those that had Medicaid expansion ballot initiatives and states in which governor races have potential implications for Medicaid expansion. In states that had governor races with implications for Medicaid expansion, changes in the composition of state legislatures are also important as governors in most states will need to work with their legislatures in order to adopt the expansion.

Outcome of Medicaid Expansion Ballot Measures

Four states voted on Medicaid expansion ballot initiatives.

Idaho. Idahoans voted in favor of Idaho Proposition 2, a ballot initiative that requires the state to submit a state plan amendment to the Centers for Medicare and Medicaid Services (CMS) to implement the Medicaid expansion no later than 90 days after the approval of the act. The Idaho Department of Health and Welfare is required and authorized to take all actions necessary to implement the provisions of this section as soon as practicable. Outgoing Governor Butch Otter endorsed the ballot initiative less than a week before the election, and Republican Governor-elect Brad Little has said he will implement the initiative.

Idaho, Nebraska and Utah voters passed ballot initiatives to expand Medicaid in the Nov. 6, 2018 election, bringing the total number of states that have adopted #MedicaidExpansion under the ACA to 37. KFF examines the implications of the election.

Montana. Montanans appear to have voted down Montana I-185 after spending on campaigns for and against the initiative made it the most expensive ballot measure race in Montana history. The measure proposed raising taxes on all tobacco products (including e-cigarettes and vaping products) and dedicating a percentage of increased tax revenues for Montana’s current Medicaid program; veterans’ services; smoking prevention and cessation programs; and long-term care services for seniors and people with disabilities. The initiative also would have eliminated the sunset date for the Medicaid expansion, which is set to expire on June 30, 2019. The Montana State Legislature, which remains in Republican control following the 2018 midterm election, could take action to continue the expansion program beyond June 2019 despite the ballot measure’s apparent failure. As of late October, tobacco companies had spent more than $17 million on advertising and other efforts to oppose the ballot measure, most of which came from cigarette maker Altria. In comparison, I-185 supporters had spent nearly $8 million, primarily from the Montana Hospital Association.

Nebraska. Nebraskans voted in favor of Nebraska Initiative 427, which requires the state to submit a state plan amendment or documents seeking waiver approval to CMS on or before April 1, 2019 to implement the Medicaid expansion. The initiative calls for the state Department of Human Services to “take all actions necessary to maximize federal financial participation in funding medical assistance pursuant to this section”. Although Governor Pete Ricketts, who was just re-elected for a second term, has been a vocal opponent of expansion, he previously stated that if expansion made it onto the ballot it would be up to voters to decide.

Utah. Voters approved Utah Proposition 3, which calls for the state to expand Medicaid coverage under the ACA beginning April 1, 2019. In addition, the initiative prohibits future changes to Medicaid and CHIP that would reduce coverage, benefits, and payment rates below policies in place on January 1, 2017. Proposition 3 calls for a 0.15% increase (from 4.70% to 4.85% of the state sales tax except for groceries) to finance the expansion or Medicaid and CHIP more broadly. Utah Governor Gary Herbert did not support the initiative (he instead favored the Legislature’s more limited approach of seeking a federal waiver to expand Medicaid just to the poverty line).

Key Governor Races with Implications for Expansion

Kansas. Democratic Governor-elect Laura Kelly has promised to advocate for and sign a bill approving Medicaid expansion in her first year in office. Although both houses of the Legislature remain in Republican control following the 2018 midterm election, expansion has received bipartisan legislative support in the past. In 2017, expansion legislation was passed by the Kansas House and Senate but was vetoed by then-Governor Sam Brownback. The House then nearly overrode the veto, but fell three votes shy (in an 81-44 vote) of the 84 votes needed to overcome the Governor’s opposition. The 2019 legislative session is set to begin on January 14th.

Maine. Medicaid expansion was adopted in Maine through a ballot initiative in November 2017. After resisting implementation of the expansion, Governor Paul LePage complied with a Maine Supreme Judicial Court order to submit an expansion state plan amendment (SPA) to the federal government in September 2018, but he accompanied it with a letter asking CMS to reject the SPA. The newly elected Democratic governor, Janet Mills, has supported Medicaid expansion and is likely to move quickly to implement. Democrats also won control of the Maine Senate, giving the party control of both houses of the Maine Legislature.

Wisconsin. The election of Democrat Tony Evers, a supporter of Medicaid expansion, over incumbent Republican Governor Scott Walker may increase the prospects of expansion in Wisconsin. The state already has a program in place to cover adults up to the poverty level through Medicaid, so unlike other non-expansion states, there is no coverage gap in Wisconsin. However, expansion to 138% of the federal poverty level under the ACA could result in additional federal Medicaid revenues and more people enrolled in Medicaid. Passage of the Medicaid expansion through the State Legislature could be a challenge even with the election of a Democratic governor, as both houses of the Wisconsin Legislature remain in Republican control. The 2019 legislative session is set to begin on January 7th. In addition, Wisconsin recently received CMS approval for a Medicaid waiver that includes work requirements, required completion of a health risk assessment as a condition of eligibility, and mandatory premiums for some Medicaid beneficiaries. Although the state now has authority to make these changes, the new governor could potentially withdraw, amend, or not implement the waiver.

Other States to Watch

Alaska. Alaska implemented the Medicaid expansion on September 1, 2015 under current Independent Governor Bill Walker. However, Republican Governor-elect Mike Dunleavy has been a critic of the state’s Medicaid expansion program and its costs and favors reviewing the program. Following the 2018 midterms, Republicans retain control of both houses of the Alaska State Legislature.

Georgia. The outcome of the Georgia gubernatorial race is still pending. Democrat Stacey Abrams is a vocal advocate for Medicaid expansion and would plan to make expansion her first priority as governor. If elected governor, Abrams would need to garner support from the legislature in order to expand coverage, as a 2014 state law prohibits Georgia’s governor from expanding Medicaid without legislative approval. However, both houses of the General Assembly remain in Republican control following the 2018 midterm election. The 2019 legislative session is set to begin on January 14th.

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What Does the Outcome of the Midterm Elections Mean for Medicaid Expansion?