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For years, elected leaders in conservative states have resisted expanding Medicaid, the government health program for low-income Americans. Now voters in four of those states will decide the question directly.
Ballot initiatives in Idaho, Utah, Nebraska, and Montana will test whether there's a disconnect between politicians and voters over a program that insures 1 in 5 Americans at an annual cost of more than half a trillion dollars to federal and state governments. Advocates behind the measures in states carried by President Donald Trump in 2016 aim to distance Medicaid expansion from the law that makes it possible: the Affordable Care Act.
"This isn't Obamacare — this is Medicaid," said Ray Ward, a Republican state lawmaker and physician from outside Salt Lake City. Ward supports widening eligibility for Medicaid in Utah, and says many of his constituents do too. While solidly Republican, his district is "not an angry sort of Tea Party district," he said.
Views of the ACA have hardened since it became law in 2010, especially among Republicans: 70% consistently find it unfavorable, according to polls by the Kaiser Family Foundation, a health-policy research group.
Prior to Obamacare, most states limited Medicaid to the very poor, blind, disabled, and pregnant women and children. Today, states can extend the program to adults earning up to about $17,000 a year for an individual, and 33 states have. Federal money pays most of the bill, but states still have to cover about 10 percent.
Nationwide, about 2.2 million uninsured people who can't get subsidized coverage would be eligible if the 17 states that haven't expanded Medicaid were to do so, according to Kaiser.
In the ballot initiatives, local advocates have joined with with professionals from the Fairness Project, a labor-backed group. It's run campaigns for higher wages in California, Colorado and elsewhere. In addition to the Medicaid initiatives this year, the Washington-based group is supporting ballot measures for minimum wage increases, paid sick time and other progressive causes in seven states, from Arkansas to Michigan.
Ballot initiatives "are so powerful because they strip away from the partisanship and the tribalism that dominates so much of our politics," said Jonathan Schliefer, executive director of The Fairness Project. "When it comes to health care, the biggest gap isn't between Republicans and Democrats. It's between politicians and everyone else," he said.
On the other side of the political spectrum, local affiliates of Americans for Prosperity, backed by the billionaire Koch brothers, are opposing the ballot measures in Utah and Nebraska. David Barnes, AFP's policy manager, said the costs may exceed what states project and that Medicaid dollars should be dedicated to vulnerable populations, not working-age adults.
Barnes said he's not surprised that even in conservative states some lawmakers want to expand the program. "It's just so difficult for people, for state legislators, to look at this and not think there's just free money coming from Washington, and they feel like they should go try to grab it," he said.
