Defending the Affordable Care Act is all the rage these days. Embattled Republicans in swing districts are embracing its consumer protections as they try to fend off Democratic challengers attacking their yea votes on repeal and replace.
Even more heartening are the battles going on in four Republican-dominated states to expand Medicaid. Utah, Nebraska and Idaho are leaning toward voting to join the ranks of the 33 states now extending coverage to people earning up to 138% of the federal poverty level. Montana voters will decide if it should remain there.
What's most notable about these initiatives is the grassroots activism that put them on the ballot. Consumer coalitions that included local provider and payer associations had to gather hundreds of thousands of signatures to bypass GOP-controlled legislatures.
Polling suggests the measures are popular. A Utah poll taken last May found two-thirds of voters supported the expansion. More than a third of voters strongly backed the measure. Less than half that number were strongly opposed.
They're also fiscally responsible. The Utah measure includes a slight increase in the sales tax to finance the state's 10% share of the expansion's costs. Montana's extension initiative includes an increase in tobacco taxes.
These states are following in the footsteps of Maine voters, who in November 2017 approved expanding Medicaid to cover low-income workers. It took a state Supreme Court order to force Gov. Paul LePage to submit the application to the federal government, which is pending.
A lot is at stake in these initiatives. Should they pass, it will generate momentum for similar grassroots efforts in Texas, Florida and Georgia—the biggest contributors to the U.S. uninsured problem. Democratic wins in close gubernatorial elections in the latter two states would create a more fertile political environment for expansion advocates.
Medicaid expansion isn't the only significant healthcare issue on ballots. Two very blue states—California and Massachusetts—are considering measures that point to serious flaws in the internal operations of dialysis providers and hospitals, respectively. However, the ballot box is the wrong place to adjudicate these issues.
The Service Employees International Union is spearheading a California ballot initiative that would cap dialysis providers' profits at 15% of costs for direct patient care and quality improvement. The industry is pouring more than $100 million into a campaign to defeat the measure, claiming it is just a ploy by the SEIU to win concessions at the bargaining table. Legislation that would do something similar was vetoed by Gov. Jerry Brown last month.
The likelihood that the measure won't pass—the unpopular pharmaceutical industry managed to defeat a similar ballot initiative to limit its pricing power in California—doesn't mean the pricing, staffing and wage policies at the nation's two huge for-profit dialysis providers, DaVita and Fresenius, don't deserve more scrutiny.
The outcomes for Americans on dialysis, while improving, are still among the worst in the developed world. The U.S. Justice Department is also investigating a premium assistance scheme used to switch patients to private insurance plans, which are then charged several times more than the bundled payments from the government-funded program.
In Massachusetts, the state's nurse association has put a minimum staffing-ratio measure on the ballot. It's opposed by all the state's major provider and insurer groups.
In an industry with the worst productivity performance in the U.S. economy, where hospital use and margins are falling, and where technology is rapidly evolving, it makes no sense to mandate rigid staffing policies. The movement toward team-based care, where everybody is working at the top of their license, is the better path to higher quality care.
Correction: The SEIU ballot initiative in California aims to cap dialysis providers' profits at 15% of costs for direct patient care and quality improvement. An earlier version of this editorial misstated misstated what the cap would be a percentage of.