Medicaid expansion scores election wins and losses across the country

Updated at 10:11 a.m. ET

From the Rocky Mountains to the Great Plains to New England, Medicaid expansion got a big boost Tuesday from successful ballot initiatives and from gubernatorial victories by Democrats in several states who made expansion a central issue.

Voters in Idaho, Nebraska and Utah approved mandatory ballot initiatives to extend Medicaid coverage under the Affordable Care Act to adults with incomes under 138% of the federal poverty level. Republican governors and lawmakers in those states had repeatedly refused to pass it.

But Montana voters rejected a ballot initiative to renew that state's Medicaid expansion and fund it by sharply increasing the cigarette tax.

Democratic gubernatorial candidates who campaigned on expansion won in Kansas and Maine, both states where Republican governors have rejected it. Those victories make expansion much more likely.

On the other hand, a Republican who opposes expansion took the governor's mansion in Florida and neighboring Georgia is still too close to call, although Republican Brian Kemp holds the lead. Democratic opponents in both states made Medicaid expansion central to their campaigns.

In Michigan, a state that already expanded Medicaid, the Democratic gubernatorial candidate prevailed against a GOP opponent who favored work requirements. Gretchen Whitmer now will have to convince GOP lawmakers not to move forward with those eligibility limits, which likely would reduce enrollment. But in Ohio, former U.S. senator and current Attorney General Mike DeWine, who supported work requirements for the state's expansion program, beat the Democrat who opposed a work mandate.

In Alaska, the fate of that state's expansion is uncertain following the gubernatorial victory of a Republican who has criticized the program's costs.

Overall, the outcome of Tuesday's Medicaid ballot initiatives and some of the governors' races pleased healthcare providers and patient advocacy groups, who predicted greater access to needed healthcare services and a significant decline in uncompensated care.

Advocates view these election successes as a springboard to expanding Medicaid in nearly all 50 states and providing coverage to millions more Americans. Up to now, the single-biggest factor in winning expansion in resistant states like Louisiana and Virginia has been the election of a governor who supports it. Polls consistently show majority public support for expansion, even in the most conservative states.

Beyond that, Affordable Care Act supporters were ecstatic that Tuesday's Democratic pickup of enough U.S. House seats to control that chamber virtually guarantees there will be no legislative rollback of Medicaid or ACA coverage for at least the next two years. That could let them shift from playing defense to pushing new initiatives on coverage expansion, consumer protections and curbing prescription drug costs.

"Tonight's election results are a resounding victory for everyone in our nation who cares about access to high quality, affordable health care," the pro-ACA group Families USA said in a written statement.

Still, the ACA's coverage gains and consumer protections remain threatened by a federal lawsuit in Texas filed by Republican attorneys general in which the judge may soon issue a ruling.

Expansion opponents, led by Americans for Prosperity, a libertarian, anti-tax group funded by the billionaire Koch brothers, argue that Democrats are hurting their states by pushing for Medicaid expansion, which they say neither the states nor the federal government can afford.

Among ballot initiatives, Idaho voters approved a measure to expand Medicaid to 60,000 people. As of early Wednesday morning, ballot initiatives were on track to pass in Nebraska and Utah, impacting 87,000 people and 62,000 people respectively. Top GOP elected officials in those states who mostly opposed the initiatives have said they would respect the will of the voters, though newly re-elected Nebraska Gov. Pete Ricketts has been tight-lipped about his intentions.

"I have talked to a number of my colleagues, and I think we will implement it and fund it properly," said Nebraska Republican state Sen. John McCollister, an expansion supporter. "That will improve the financial health of our rural hospitals big time."

In Montana, expansion foes, backed by an estimated $17 million in Big Tobacco money, defeated a ballot initiative that would have renewed that state's Medicaid expansion covering 90,000 low-income adults and funded it with a $2 per pack tax on cigarettes and a new tax on vaping products.

If it had passed, those Montanans would have been able to keep their coverage as is. Now it will be up to the Republican-controlled Legislature to decide the program's fate when it expires in June.

GOP lawmakers may seek a Medicaid waiver to roll back the expansion to a smaller number of people and impose a work requirement, which would leave many Montanans uninsured and drive up uncompensated care costs, said Jean Branscum, CEO of the Montana Medical Association, which supports the current expansion program.

Here is how the election played out in key states around the country.

(For more election results, visit Modern Healthcare's 2018 Midterm Elections Tracker.)

Alaska

Republican Mike Dunleavy defeated Democrat Mark Begich for the governorship of this state, where current independent Gov. Bill Walker had pushed through a Medicaid expansion covering 40,000 people.

Dunleavy was critical of the expansion program's costs and had called for reviewing it, a position in line with some members of the state's Republican-controlled Legislature. It remains to be seen what he will do with the program.

Florida

Former Republican congressman Ron DeSantis defeated Tallahassee Democratic Mayor Andrew Gillum in the governor's race. Gillum had placed Medicaid expansion, along with "Medicaid for all," at the heart of his campaign, while DeSantis strongly opposed it.

Georgia

Republican Secretary of State Brian Kemp held a lead over Stacey Abrams, a Democratic former Statehouse minority leader, who also made Medicaid expansion the marquee issue of her campaign. She argued it would reduce high maternal and infant mortality rates, drive down uncompensated care, and save rural hospitals in a state where seven have closed since 2013.

The Georgia Hospital Association and business groups are likely to continue to push for a more limited form of expansion, through a Medicaid waiver.

"We continue to emphasize that Georgia tax dollars go to support expansion in other states, and we're losing out on billions of federal healthcare dollars, with an impact on our economy, our workforce and ensuring access to care," said Ethan James, the hospital association's executive vice president of external affairs.

Kansas

Democrat Laura Kelly, a state lawmaker who beat Republican Secretary of State Kris Kobach for the governorship, promised to cover 150,000 Kansans by passing Medicaid expansion in her first year in office. She said it's critical for keeping rural hospitals and clinics open.

Analysts say passing expansion is plausible in this deep-red state where the GOP-controlled Legislature passed expansion last year but narrowly failed to override former Republican Gov. Sam Brownback's veto.

Republican state Rep. Susan Concannon, an expansion supporter, expressed cautious optimism in September that if Kelly won, she could get a new expansion bill through the Legislature.

"If we have a governor who would sign the bill, I would find a way to get it to the floor," she said. "It would be a difficult vote for some conservatives in rural areas because their communities want it, but politically they don't want to vote for it."

She thought it would help if voters in neighboring Nebraska approved the ballot initiative to expand Medicaid, which they did Tuesday. "If it's right next door, it's right in front of our face, and that would make a difference," Concannon said.

Maine

Democratic state Attorney General Janet Mills, who favors expansion, beat Republican Shawn Moody, who opposed it.

Maine voters overwhelmingly approved expansion in a ballot initiative last year, but current Republican Gov. Paul LePage has defied court orders to implement it.

Governor-elect Mills is expected to quickly push through the expansion, with the help of Democratic election gains in the Legislature made on Tuesday.

Michigan

Democrat Gretchen Whitmer, who favors keeping the state's Medicaid expansion without a work requirement, won the governor's race over Republican Bill Schuette, who wanted to establish a work requirement. The Healthy Michigan program covers about 650,000 people.

Whitmer, who helped pass Michigan's expansion, warned that the real goal of the work requirement is to take coverage away from people, and that could be "devastating."

Chris Mitchell, senior vice president of advocacy for the Michigan Health and Hospital Association, which strongly supports the expansion, said in September that it's unlikely that Whitmer's victory would derail the work requirement waiver, which was mandated by the GOP-controlled Legislature and backed by Republican Gov. Rick Snyder.

The state hospital association expects the work requirement to be approved soon by the CMS. It would take a major effort by the next Legislature and governor to significantly change that, Mitchell said. He noted, however, that lawsuits challenging the CMS' approval of the work requirement waivers in Kentucky and Arkansas are a wild card.

Legislative analysts predict the work requirement would cause 5% to 10% of beneficiaries to drop out of coverage.

Ohio

The same disagreement over a work requirement played out in the Ohio governor's race, which was won by Republican Mike DeWine over Democrat Richard Cordray.

The Ohio expansion pushed through by Republican Gov. John Kasich covers nearly 700,000 people.

Wisconsin

Early Wednesday morning, State Education Superintendent Tony Evers was declared the winner in a tight race against incumbent Republican Gov. Scott Walker, who has resisted a full expansion of Medicaid to people up to 138% of the federal poverty level.

Evers has vowed to accept federal Medicaid expansion dollars "on Day 1" of his governorship. But that will be a hard promise to keep. The state House Republican leader, Robin Vos, has said a reconsideration of Walker's decision against expansion is "not gonna happen. No. Never"—even though Republicans lost legislative seats in Tuesday's election.