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What the Midterms Mean for Health Care

The trajectory of health policy -- from Medicaid to abortion to soda taxes -- is set for change in some states.

Nebraska's Initiative 427, the Medicaid Expansion Initiative, passed with 53 percent of the vote.
(AP/Nati Harnik)
The 2018 midterms have largely been a referendum on the Trump administration and its policies. It was no different with health care.

Voters on Tuesday had a say on everything from Medicaid expansion to abortion to universal at-home care. The results were mixed, with voters splitting on some divisive health-care ballot measures. And in some states, the governor's race could change the trajectory of health policy.

Here’s a breakdown of the big election results that impact health care.


Medicaid Expansion

Medicaid expansion was the big winner of the night, with three states -- Idaho, Nebraska and Utah -- approving expansion measures. Only Montana’s measure, which would have raised cigarette taxes to continue funding the state’s existing Medicaid expansion program, appears to have been defeated.

In Idaho and Nebraska, the measures passed with 63 percent and 53 percent of the vote, respectively.  

Utah's measure, meanwhile, passed with 54 percent of the vote. But unlike Idaho and Nebraska, Utah already has a law in place to expand Medicaid. It's awaiting federal approval, but if granted, would require nondisabled people to work, volunteer or participate in a job training program to receive Medicaid; would automatically end the expansion if the federal match dipped below 90 percent; and would stop eligibility at the poverty line, which is $12,140 for a single person. (The federal government has rejected other states' requests to limit expansion to people at the poverty line.)

The ballot measure, on the other hand, asked voters to expand Medicaid traditionally -- without work requirements or eligibility limits. It also asked voters to increase the sales tax to fund the state's 10 percent share of the costs. It’s unclear what would happen, now that the ballot measure passed, if the federal government approves Utah’s competing Medicaid waiver.

Health policy experts were uncertain how these ballot measures would fare, particularly given how conservative the states are. In Idaho, GOP Gov. Butch Otter’s endorsement of the ballot measure one week before the election helped. Its wide approval margin can be credited to his backing, says David Jones, associate professor of health law at Boston University.

Adam Morfeld, a Nebraska state senator who campaigned heavily for the ballot measure, says he was “pleasantly surprised” by the margin of victory in his state.


Governors Races and Medicaid

Beyond the ballot, Medicaid expansion advocates were also closely watching a number of governors' races.

In particular, they were hoping for Democratic victories in Florida and Georgia. If Democrat Andrew Gillum had won in Florida, many expected a Medicaid expansion would follow. But he conceded Tuesday night and, while the Georgia race has not been called, Democrat Stacey Abrams is trailing in the polls.

Even if Gillum had won, says Boston University's Jones, given the makeup of the Florida Legislature, “I think it would have been an uphill battle.”

Meanwhile, advocates have something to cheer about in Maine, where voters approved an expansion in 2017. Outgoing GOP Gov. Paul LePage, citing concerns about the cost, has refused to implement it. But now that Democrat Janet Mills has won the race, experts say, it’s safe to assume she'll expand Medicaid.

One win for Medicaid expansion that many advocates didn’t see coming was the Kansas governor's race. State Sen. Laura Kelly, a Democrat, defeated Secretary of State Kris Kobach, a Republican.

The Kansas Legislature came close to expanding Medicaid in 2017, but then-GOP Gov. Sam Brownback vetoed the bill. With a Democrat soon to be in power, says Jones, Kansas is "the next battleground state for Medicaid expansion.”

And finally, five states that expanded Medicaid and are pursuing waivers such as work requirements, income reporting and premiums, held gubernatorial elections on Tuesday. Republicans maintained control in Arizona, New Hampshire and Ohio, and therefore, are expected to continue pursuing waivers.

But two -- Michigan and Wisconsin -- elected Democrats, signaling a push to the left on health-care policy. Michigan Gov.-elect Gretchen Whitmer and Wisconsin Gov.-elect Tony Evers have both said they oppose any restrictions on eligibility and could withdraw the waivers.



While only three states voted on the issue, the measures were seen as a referendum on abortion rights in an era of uncertainty over the future of Roe v. Wade, the 1973 case that legalized abortion. The appointment of Brett Kavanaugh to the U.S. Supreme Court has given it a solid conservative majority.

Voters in West Virginia narrowly passed a ballot measure that will eliminate Medicaid coverage of abortion services in the state. With 96 percent of precincts reporting, Amendment 1 passed with 51 percent of the vote.

The measure also includes provisions that would only be enforceable if Roe v. Wade is overturned: It bans abortion in the state and changes the state’s constitution to ensure that nothing in it “secures or protects a right to abortion or requires the funding of abortion." It also makes receiving or performing an abortion punishable by up to 10 years in jail.

Alabama's ballot measure, meanwhile, was approved 59 percent to 40 percent. Like in West Virginia, it is largely unenforceable at the moment. It will not only change the state’s constitution to explicitly state that there is no right to an abortion but will also recognize the "sanctity of unborn life and the rights of unborn children, including the right to life."

Fetal rights propositions are controversial, even among some pro-life advocates. Recognizing fetal rights could criminalize some forms of birth control or fertility treatments. Mississippi, a red state, had a measure on the ballot in 2011 that would have established life as beginning at conception. It was ultimately defeated.

Alabama's approval of a fetal rights measure signals a further push to the right on abortion in solid red states. “The language is just so broad and vague in Alabama,” says Elizabeth Nash, state policy expert for the Guttmacher Institute, a research organization that supports abortion access. "It could complicate your right to health care, say, if you had a miscarriage or if you were in a car accident while pregnant."

Oregon, on the other hand, defeated a ballot measure 66 percent to 34 percent that would have ended abortion benefits for public employees and women on Medicaid. Oregon is one of 17 states (now 16, with West Virginia dropping from the list) that allows taxpayer dollars to fund abortion coverage for public health plans. This is the fourth time Oregonians have voted down abortion restrictions in the past few decades.

One thing is certain from last night’s abortion measures: More states are likely going to take action to move abortion access to the right or left.

“We’re going to see constitutional amendments [on abortion access] coming into play more in general,” Nash says.


Split on the Soda Tax

Observers were watching two similar ballot measures in Oregon and Washington state to gauge the viability of soda taxes. But much like the rest of the results from Tuesday night, the results were mixed.

The two ballot measures would ban any new local taxes on groceries, excluding tobacco, marijuana and alcohol. Oregon rejected its measure, while Washington voters appear to have passed its grocery tax ban. With 64 percent of precincts reporting, 54 percent were in favor.

Oregon’s initiative would have retroactively applied to any tax passed after Oct. 1, 2017, which means it would have killed a soda tax passed in Multnomah County.

The two ballot initiatives were framed as soda tax referendums because they were largely funded by big soda companies.

In other tax news, Nevada voted to become the 16th state to nix the tampon tax. And South Dakota rejected a measure on a cigarette tax that would have funded a job training program.


Other Health News From Election Night

Maine voters turned down a proposal that would have established the nation's first state-run universal at-home care program, losing 63 percent to 36 percent. Even if it had passed, implementing it could have been an uphill battle as none of the gubernatorial candidates endorsed the measure.

Massachusetts voters declined to adopt a controversial initiative that would have limited the number of patients that a nurse could treat during one shift. The measure split nursing interest groups, with a nurses union in support of it, but the Massachusetts Health and Hospital Association spent big to defeat it.

It would have been the second state with nurse-to-patient ratio requirements, after California adopted a similar law in 1999. Results from California’s experiment have been mixed: While a study found that patient outcomes improved after the law was enacted, the state is also facing an impending nurse shortage -- although it’s impossible to say what impact the law had on both of those events.

Mattie covers all things health for Governing.

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