by Guinn Center staff
Medicaid is the nation’s largest provider of health care coverage, covering more than 73 million Americans and accounting for nearly 16 percent of national health care spending. Medicaid expansion, one of the Affordable Care Act’s (ACA) primary coverage initiatives, provides Medicaid coverage to adults between the ages of 19-64 years old with incomes below 138 percent of the federal poverty level (FPL) in all states. However, the expansion was subject to a legal challenge, and, in National Federation of Independent Business v. Sebelius, in 2012, the U.S. Supreme Court ruled that the choice to expand (or not) fell under the purview of each state.
Before the General Election on November 6, 2018, 33 states and the District of Columbia had opted to expand Medicaid coverage, including Nevada. This means that 17 states had not implemented the expansion, though it reduced coverage gaps elsewhere. For example, in Nevada, Medicaid expansion has contributed to significant reductions in the state’s rate of uninsured, dropping from 20.7 percent in 2013 to 11.2 percent in 2017. In fiscal year (FY) 2018, nearly 215,000 Nevadans received coverage as a result of Medicaid expansion.
With the midterms came renewed interest in health care. One tracking poll indicated that a majority of voters cited the issue as “very important” to their vote choice, and a quarter deemed it the “most important issue,” above all others. Moreover, three states—Idaho, Nebraska, and Utah—put the question of Medicaid expansion to the voters in the form of ballot initiatives. A fourth state, Montana, put forth a ballot initiative on the question of continued funding for its Medicaid expansion program.
We examine the outcomes of the ballot measures and the implications of the gubernatorial races in this past election, the results of which, collectively, suggest continued enthusiasm for reducing the uninsured rate and closing coverage gaps. In light of this momentum, might Nevada consider other coverage expansion policies in the forthcoming 80th (2019) Legislative Session?
The 2018 General Election and Medicaid Expansion Ballot Initiatives
Motivated by the concern that some residents of Idaho, Nebraska, and Utah lacked access to affordable health care, coalition campaigns formed to remedy the problem by placing the question of Medicaid expansion to the votes. Proponents in the respective states—Reclaim Idaho, Insure the Good Life (Nebraska), and Utah Decides—also stressed the economic benefits of Medicaid expansion, including, amongst others, job creation and new revenue.
In Idaho, 60.4 percent of voters favored the Medicaid expansion ballot initiative, Proposition 2. More than fifty (53.2) percent of Nebraskans voted for Initiative 427, its version of Medicaid expansion. And Proposition 3 in Utah, designated on the ballot as Medicaid expansion, was approved by roughly 54.1 percent of that state’s voters. Passage of these ballot initiatives is estimated to provide health care coverage to 62,000 additional Idahoans, 150,000 Utahns, and 90,000 Nebraskans. The wins in Idaho, Nebraska, and Utah mark 2018 as the year with the most states set to expand Medicaid since 2014, which was the first year that expansion became an option for the states.
However, in Montana, a state that expanded Medicaid in 2015, 52.9 percent of voters rejected Initiative No. 185, which would have continued financing its Medicaid program by instituting a $2-per-pack increase on cigarettes. Montana’s Medicaid expansion is set to sunset next July, but the Legislature and the state’s governor are expected to address the issue in the upcoming legislative session that begins in January.
It should be noted, too, that Maine voters approved Medicaid expansion via a 2017 ballot initiative, but it has not been implemented and is now the subject of litigation.
The 2018 Midterm Election: Gubernatorial Races and Medicaid Expansion
The outcomes of the gubernatorial races in Kansas, Maine, and Wisconsin could mean that Medicaid expansion is on the horizon in those states. In both Kansas and Maine, legislation previously has been passed to expand Medicaid, but Governors Sam Brownback (Kansas) and Paul LePage (Maine) opposed and vetoed prior legislative efforts.
Unlike their predecessors, the governors-elect of Kansas (Laura Kelly) and Maine (Janet Trafton Mills) have expressed support for Medicaid expansion. Additionally, in Wisconsin the newly-elected Governor (Tony Evers) campaigned on Medicaid expansion, though legislative opposition in the state may present challenges. If Medicaid is expanded in these three states, an estimated 200,000 individuals would gain coverage in Kansas and Maine and approximately 80,000 would be eligible for Medicaid expansion in Wisconsin.
Other Proposed Coverage Expansion Initiatives in Nevada
Although Nevada has seen marked improvements in its rate of uninsured, about 333,000 Nevadans remain uninsured as of 2017. And, as we documented in our 2017 policy brief, “Medicaid Funding in Nevada,” state funding of the program has increased 45.1 percent between FY 2013 and FY 2016. In an effort to increase access to affordable coverage, Assembly Bill (AB) 374 was introduced in the 2017 (79th) Legislative Session. This bill would have made Medicaid managed care plans available to Nevadans who were not otherwise eligible for Medicaid. These plans are part of a health care delivery system designed to manage cost, utilization, and quality through contracted arrangements between state Medicaid agencies and managed care organizations.
Although AB 374 was passed by the Nevada Legislature, Governor Brian Sandoval vetoed it, noting that it was a creative policy but required additional study and analysis. The primary sponsor of the bill, Assemblyman Mike Sprinkle, has indicated that the bill will be reintroduced in the 2019 (80th) Legislative Session. The recent election results suggest that health care remains a priority for many voters and that the issue of Medicaid expansion will remain a subject of discussion among state legislators and political leaders.