Six times since 2017, voters in a state have weighed directly whether they expand Medicaid and ensuring that more low-income adults are eligible for free public health coverage. The voting measure was successful six times.
That undefeated streak could go up to seven wins in South Dakota in November.
On Election Day, voters decide on: a constitutional amendment that would expand Medicaid’s eligibility under the Affordable Care Act. If it succeeds, anyone earning less than 133 percent of the federal poverty level (about $18,000 for an individual or $36,900 for a family of four) would qualify for Medicaid coverage. Currently, 5 percent of the state is uninsured. Childless adults of working age may not qualify for coverage at all. Pregnant women, children and the elderly can currently receive Medicaid benefits, but working parents must be on very low incomes — less than 63 percent of the federal poverty level, about $17,500 for a family of four — to enroll.
An estimated 45,000 South Dakotas would be covered by the extension, adding to 20.4 million low-income Americans nationwide already secured by the Medicaid expansion since the program went into full effect in 2014. Many of those who would qualify for Medicaid in South Dakota – about 14,000 — are Native Americans who are not currently eligible for coverage. Voting initiative appears to have a good chance of succeeding in November: poll commissioned by the American Cancer Society Finds Cancer Action Network 62 percent of voters in South Dakota said they support the measure.
Initially, the Affordable Care Act was intended to extend Medicaid coverage to low-income adults nationwide. The law offered a good deal: Expand eligibility and receive a generous federal funding match, 90 percent of the cost forever. But a 2012 Supreme Court decision made Medicaid extension optional for states, and a dozen states still haven’t accepted the extension a full decade later, leaving 4 million people without Medicaid coverage that would otherwise qualify.
Faced with that impediment from Republican state officials, health care proponents have taken the issue directly to voters in largely Republican states, with remarkable success.
About the six states that expanded Medicaid by means of a voting measure — Idaho, Maine, Missouri, Nebraska, Oklahoma, and Utah — an estimated 811,000 people are enrolled or eligible for Medicaid coverage. It is a new frontier for expanding access to health insurance in America. I asked Paul Starr, a Princeton University sociologist and the leading historian of the American health system, if there was a precedent for direct democracy that led to significant coverage expansions.
“The history of health insurance protection until the Supreme Court’s decision on the ACA in 2012 was almost entirely a history of legislation and administrative decisions,” he told me. “The mood measures were not very significant.”
But voting initiatives in recent years have become almost exclusively the path for Medicaid expansion to continue. In the first few years after the Supreme Court ruling, a number of Republican state leaders decided to take over the expansion of Medicaid on their own, driven by the financial benefits and lobbying of local health organizations. The Obama administration accepted waivers — including one from future Vice President Mike Pence, then Indiana governor — to modify the program to make it more accessible to these GOP politicians.
But by 2017, when Donald Trump entered the White House, the prospects for future action by Republican governors and lawmakers looked bleak. So the Fairness Project, an offshoot of an SEIU health workers’ union in California that backed minimum wage voting initiatives at the time, began coordinating with local organizers to put Medicaid expansion right on the ballot.
“Direct democracy has been a path for significant change as well as a last resort,” said Kelly Hall, a former Obama administration health official and now the executive director of the Fairness Project. “Expanding Medicaid everywhere will protect it everywhere.”
Recent years have been a revelation of Medicaid’s political potential. Concerns about ending expansion and cutting Medicaid spending helped thwart Republican plans to repeal and replace the ACA. And these six expansion voting initiatives have all passed since 2017, and South Dakota is on the cusp of its seventh.
Hall said the goal of the campaign was “to help place Medicaid alongside other third-track public programs like Medicare and Social Security.”
“Medicaid has a much broader base than many people appreciate,” Starr told me. “It’s not just the poor who benefit. It is also people with disabilities and seniors, plus their families and the providers who benefit from Medicaid payments.”
GOP leaders have still tried – unsuccessfully so far – to stop or undermine these voting initiatives, first in Utah and Missouri, and now in South Dakota. Ahead of the June primaries, the state legislature passed a ballot measure that would have required a 60 percent supermajority to pass future ballot initiatives, with the intent of making it more difficult for Medicaid’s expansion measure. But it was rejected by two-thirds of South Dakota’s main voters.
Why does the expansion of Medicaid continue to find success with voters in the red state, if not with their elected representatives? Hall pointed to three successful messages: hearing from neighbors taking advantage, returning federal tax dollars to the state, and protecting the solvency of rural hospitals and health clinics. One of the ads Running in South Dakota features a farmer who says he wants to keep his family farm going but can’t afford health care right now.
To date, Medicaid’s expansion initiatives have been an unqualified success. But their usefulness may soon run out. Only about half of the states allow citizen-initiated ballot measures, and of the 12 states that have not expanded Medicaid, only four of them allow such initiatives: South Dakota — which is already voting on it this fall — plus Florida, Mississippi. and Wyoming.
Florida is the second largest state, after Texas, still refusing Medicaid expansion. Those two states are home to more than half of the 2.2 million people across the country who have been left without a viable option for coverage because their state has not expanded Medicaid. But while voting initiatives are allowed there, they require a 60 percent supermajority and the state legislature has shown a willingness to undermine voting measures after their passage.
The entire Mississippi ballot initiative process, meanwhile, was… upended by a decision of the state court in 2021; advocates are working to restore citizens’ right to collect signatures and raise issues directly to voters. In Wyoming, there is some hope that the legislature and governor may still come on board with Medicaid expansion while the state faces budgetary difficulties.
So while voting measures may still bring more gains in expanding Medicaid coverage, expansion proponents are running out of opportunities. Texas, for example, is one of the states that does not allow citizen-sponsored voting initiatives. Nor is Georgia or North Carolina, the second-largest states after Florida, for not expanding it.
“We’re pretty close to working ourselves out of a job on this topic,” Hall said.
But the work still won’t be done until Republicans get by in these other states, Democrats can win statewide elections, or Congress Decides to Take Action to Close the Medicaid Expansion Gap for Good.