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Red-State Voters Opt for Obamacare

In the first referendum on the law since Congressional Republicans tried and failed to repeal it, three out of four states voted to expand Medicaid.

Medicaid Expansion Utah
People marching in Salt Lake City to protest Republican efforts to repeal the Affordable Care Act.
(AP.Rick Bowmer)


  • Three states voted to expand Medicaid -- Idaho, Nebraska and Utah.
  • A ballot measure to extend Medicaid expansion, and fund it with increased cigarette taxes, failed in Montana.
  • Medicaid expansion is a central tenet of President Barack Obama's Affordable Care Act (ACA). It makes people living up to 138 percent of the federal poverty line eligible for Medicaid, the government-run health insurance program for the poor.
  • Only one state, Maine, had approved Medicaid expansion through the ballot box before Tuesday.
  • It was the first time voters directly weighed in on provisions of the ACA since Congressional Republicans tried to repeal it.
In a test of support for President Barack Obama's Affordable Care Act (ACA), voters approved Medicaid expansion in three red states on Tuesday -- Idaho, Nebraska and Utah. It was the first referendum on provisions of the ACA since Congressional Republicans tried and failed to repeal it last year.

Montana voters, however, rejected their Medicaid expansion measure on the ballot.

Supporters of Medicaid expansion see it as a vital part of the social safety net, especially because qualifying for Medicaid in nonexpansion states can be tough. Opponents, however, see expansion as fiscally irresponsible since states will start picking up 10 percent of the costs in 2020.

Montana expanded Medicaid in 2015, but under the deal struck in the state legislature, it is set to expire June 30. Residents were voting on whether to extend it, and how the state would fund their portion of it. The ballot measure proposed hiking taxes on tobacco products to $2 per pack.

Tobacco interests spent $17 million to defeat the ballot measure.

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

Utah had already passed a bill to expand Medicaid, but it is awaiting federal approval. It would require nondisabled people to work, volunteer or participate in a job training program; the expansion would automatically end if the federal match dipped below 90 percent; and eligibility stops 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, meanwhile, asked voters to expand Medicaid traditionally -- without work requirements or eligibility limits past the federal poverty line. It also asked voters to increase the sales tax to fund the state's share. It passed with 54 percent of the vote.

It’s unclear what would happen if the ballot measure passes and the federal government approves Utah’s competing Medicaid waiver. 

Maine became the first state to expand Medicaid at the ballot box in 2016. But it hasn’t been smooth sailing. Maine's outgoing Republican governor has taken every opportunity to block the expansion -- even asking the federal government to reject the state's Medicaid expansion application that the courts made him send.

But the passage in Maine alone galvanized health-care advocates who wish to see Medicaid expansion in the dozen or so states that have declined federal money to offer health insurance to the people who fall in a "coverage gap," where they make too much money to qualify for Medicaid but can't afford private insurance. 

While the price tag of Medicaid expansion can come with some sticker shock, independent analyses have found that states often save money by insuring people -- there are fewer instances of uncompensated care, and people are healthier when they have insurance. According to a 2016 report from the Robert Wood Johnson Foundation, 11 states experienced some savings from Medicaid expansion.

"Proponents insist that it’ll pay for itself, but entitlement programs are historically costlier than anticipated. I imagine there are going to be some really tough discussions," said Fred Birnbaum, vice president of the Idaho Freedom Foundation, which opposed the measure.

For results of the most important ballot measures, click here.

Mattie covers all things health for Governing.

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