Expected in 2019: Five more Medicaid expansion states. And more could follow.


November 13, 2018

More than 800,000 residents in five states could soon be covered by Medicaid expansion, due in part to last week’s election results and in part to decisions that were made prior to the elections. And more could follow.
Let’s do the Medicaid expansion math. As it stands today, 31 states plus D.C. have implemented Medicaid expansion. On Jan. 1, 2019, about a month and a half from now, Virginia will become the 32nd state, and 400,000 low-income residents will qualify under Medicaid expansion. This is because Virginia Gov. Ralph Northam worked with Democrats and moderate Republicans in the General Assembly earlier this year to pass expansion.

Sometime in early 2019, Maine will become the 33rd state to implement Medicaid expansion. Voters actually approved expansion in November 2017 – but Maine’s intransigent governor, Paul LePage, defying the will of the voters, refused to move toward implementation. Now Maine has elected a pro-expansion governor, and she has pledged to put the new law in place without delay. That will expand Medicaid coverage to an additional 70,000 Mainers.

Enter last Tuesday. Voters in three states – Idaho, Nebraska, and Utah – approved Medicaid expansion. It will take roughly three to four months for these states to submit plans to the federal government for approval, but once plans are implemented, an additional 363,000 people could be covered, and the number of states approving Medicaid expansion will grow to 36, plus D.C.

(The news from last Tuesday was not all rosy. A ballot initiative that would have continued funding Montana’s Medicaid expansion beyond June 2019, in part by adding a $2 cigarette tax, narrowly failed, after tobacco companies poured in $17 million to defeat it. But advocates say they will continue to push for money to keep the expansion going after the June sunset.)

For Idaho, Nebraska, and Utah, roadblocks exist. Legislators in these states for years have refused to approve Medicaid expansion, and the Nebraska governor campaigned against the measure, although he has pledged he will not block the will of the voters. Opponents could drag their feet or pass onerous restrictions that make it difficult or impossible to qualify for Medicaid.

Patrick Willard, Senior Director of State and National Strategic Partnerships for Families USA, cautions:

“While we are incredibly thrilled by the ballot initiative results, the work to get people access to coverage is far from over….Lawmakers have an obligation to implement the ballot initiatives, which are now state law, just as they would with any other law that the governor would sign. Families USA and state partners have every reason to believe that state lawmakers will fulfill their obligation to the constituents of their states by upholding the new law to expand Medicaid in their states and submitting the State Plan Amendment (SPA) by the deadlines.”

Jesse Cross-Call, Senior Policy Analyst for the Center on Budget and Policy Priorities, has three pieces of advice for the three states:

Move quickly to submit SPAs. [In Utah and Nebraska, the ballot initiative language requires that SPAs be submitted to the federal government by April 1, 2019; in Idaho, that deadline falls in early March.]

Pursue streamlined enrollment strategies. States have the option to identify participants in SNAP who are certain to be eligible for Medicaid, notify them that they may qualify, and ask if they want to enroll. That lets states enroll large number of eligible people quickly, and without having to furnish duplicative paperwork. Recent expansion states like Louisiana and Virginia have successfully used this option – each of those two states had hundreds of thousands of eligible recipients even before expansion took effect.

Avoid policies that create barriers to coverage and care. The Trump Administration has approved Medicaid waivers in five states that let them charge beneficiaries premiums and increase their cost-sharing, as well as take coverage away from beneficiaries who don’t meet rigid work requirements. These requirements are complex and confusing, leave fewer people enrolling in coverage, and don’t improve health outcomes.

So where are we in terms of Medicaid expansion and what comes next?

If you look at the map above, you will find that, after the five aforementioned states implement Medicaid expansion, 14 states remain that have no plans to implement expansion. These 14 states are largely in the South and in the Midwest.

As a result of last week’s elections, efforts to expand Medicaid are expected to escalate in three states: Kansas and Wisconsin, which elected pro-expansion governors; and North Carolina, which already has a pro-expansion governor, but where Democrats appear to have picked up enough seats in each legislative chamber to “break” the GOP’s super-majority hold.

These fights will be uphill, to be sure; Republican legislative leaders in Wisconsin have vowed to block expansion, and relations between North Carolina’s governor and the state’s legislative majority are frosty. In Kansas, however, some advocates think expansion is possible, and soon. The Kansas Legislature approved Medicaid expansion in 2017, but it was vetoed by Gov. Sam Brownback. The new governor has stated that she hopes to pass a bipartisan expansion plan before the legislature adjourns in spring 2019.

Whatever happens in Kansas, and in Wisconsin and North Carolina, it will not be the last word on Medicaid expansion. Advocates in other non-expansion states will be heartened by the recent successes and may well choose to wage campaigns to qualify pro-expansion ballot measures for the 2020 election cycle.




Affordable Care Act