Americans bringing Medicaid expansion to state ballots: Grassroots support
==========================================================================

* Mark Barna

![Figure1](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/50/7/1.2/F1.medium.gif)

[Figure1](http://www.thenationshealth.org/content/50/7/1.2/F1)

Luke Mayville, cofounder of Reclaim Idaho, speaks in 2018 to Idahoans about Medicaid expansion. The grassroots campaign collected 60,000 signatures, bringing the issue to the state ballot and making expansion a reality in Idaho.

Photo courtesy Reclaim Idaho

For months, date nights in Idaho for Rebecca Schroeder and her husband consisted of knocking on doors and standing on porches advocating for Medicaid expansion.

The grassroots effort, which involved hundreds of statewide participants, gathered 60,000 signatures, qualifying it for the state ballot. In November 2018, Medicaid expansion in Idaho was approved by 61% of voters. Today, more than 80,000 additional low-income Idahoans have health care coverage under Medicaid because of those efforts.

“It has probably been the best thing to happen in Idaho in decades,” Schroeder, executive director of Reclaim Idaho, which led the effort, told *The Nation’s Health.*

Expanding Medicaid through a public initiative process has been a successful strategy in states represented by governors or lawmakers who oppose expansion. In 2017, Maine voters were the first to bypass politicians and approve expansion. One year later, Nebraska and Utah passed it on mid-term ballots.

The trend has continued this year. In July, a slim majority of Oklahoma voters said “yes” on the primary ballot, leaving only 13 states that have not expanded Medicaid since the Affordable Care Act went into effect in 2010. Missouri residents were planning to vote in August on whether to expand the program, and advocates in Florida plan to place it on the mid-term ballot for 2022. Expansion is also being debated in Kansas and Texas.

“Hopefully, we provided some inspiration for folks who are still waiting on politicians to do the right thing,” Amber England, campaign manager of Oklahoma Yes on 802, told *The Nation’s Health* a few days after the 802 ballot measure passed by 6,500 votes. Over 200,000 additional low-income Oklahomans will qualify for Medicaid when the expansion goes into effect in summer 2021.

The ACA offers states the option to expand Medicaid to single adults and families making up to 138% of the federal poverty level — $16,642 for an individual, $24,600 for a family of four — which is higher than what standard Medicaid allows. The health impact of expanding Medicaid is well known, with a study last year finding 15,600 older adults died prematurely because of state decisions not to expand Medicaid.

![Figure2](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/50/7/1.2/F2.medium.gif)

[Figure2](http://www.thenationshealth.org/content/50/7/1.2/F2)

Graphic by Aaron Warnick, courtesy Datawrapper

The economic benefits to states are substantial as well.

The federal government pays for at least 90% of Medicaid expansion by sending tax dollars back to the state. States fund the final 10% in part from money not spent paying medical costs for people who are uninsured.

In February, a *New England Journa*l *of Medicine* study reviewed health spending in the District of Columbia and the 37 states that have expanded Medicaid. Researchers found that federal dollars paid for almost the entire cost, with states using funds to subsidize rural hospitals and mental health centers.

“Medicaid expansion appears to be a win-win from the states’ perspective — giving health insurance to millions of low-income adults and offering financial support to safety net hospitals, without any adverse effects on state budgets,” the researchers said.

The effect of expansion on state budgets is “minimal or positive,” Adam Searing, an associate professor at Georgetown University Center for Children and Families told *The Nation’s Health.*

In 2017, Reclaim Idaho created a statewide grassroots movement to collect enough signatures to get the initiative on the ballot. Medicaid expansion was desperately needed because of high poverty and closures of multiple hospitals, Schroeder said.

To draw attention to the effort, an old Dodge camper was spray-painted bright green and “Medicaid for Idaho” was stenciled across its camper shell. Some Idahoans signed not only the petition but the truck itself.

> “Having thousands of people uninsured when there is insurance on the table, 90% covered with federal funds, is not acceptable. It is morally wrong.”
> 
> — Rebecca Schroeder

Expansion went into effect on Jan. 1, 2020, and this year $400 million in federal funds has flowed into Idaho’s health care system, helping keep rural hospitals open and people healthy, Schroeder said.

The timing paid off. Beginning in March, furloughs and layoffs and loss of employer-based health  insurance impacted many Idahoans who, without Medicaid expansion, would otherwise have had no health coverage.

Indeed, millions of Americans have lost jobs and their employer-based health insurance because of the COVID-19 pandemic. During the early months of the crisis, from February to May, 4.5 million workers lost their health insurance in the U.S., according to a July study from Families USA. By the end of the year, over 10 million people will likely be without health care coverage, the Urban Institute and the Robert Wood Johnson Foundation estimated in a July report.

“The pressure will continue to build on states that have not expanded Medicaid as the magnitude of the (pandemic) crisis grows,” Schroeder said. “Having thousands of people uninsured when there is insurance on the table, 90% covered with federal funds, is not acceptable. It is morally wrong.”

States using public initiatives have been challenged by opponents, including lawmakers, even as polls show Americans overwhelmingly support Medicaid expansion. Two-thirds of residents in states whose officials oppose expansion support broadening the program, a May Kaiser Family Foundation poll found. And over 70% of households that experienced a job or income loss due to COVID-19 support expansion.

Idaho and Oklahoma passed expansion measures by leaving politics out of the discussion and speaking plainly about expansion’s positives to residents.

In Idaho, volunteers delivered a simple message: We already pay for it.

“We are already paying the federal taxes for this and right now we are not getting the health care that we are paying for,” Schroeder said she told residents. “But we are paying again when uninsured people show up in the emergency room needing care. It makes sense that preventive managed care is both cheaper for the taxpayer and better for patients.”

In Oklahoma, volunteers appealed to people’s general belief that health care is important.

“People in Oklahoma want to step up and help their family, friends and neighbors, so just knowing that 200,000 Oklahomans were going to get care was important, as well as saving rural hospitals,” England said.

Since 2016, eight rural hospitals have declared bankruptcy and six have closed in Oklahoma.

Much of Oklahoma’s Yes on 802 campaign unfolded during the pandemic, so knocking on doors to gather signatures was not on the table in some counties. Supporters used social media, telemarketing and texting to reach voters. Volunteers gathered 313,000 signatures, the highest for any ballot measure in Oklahoma history.

“You have to give people hope, and by and large our campaign was aspirational,” England said. “It brought people together.”

In July, advocates were hopeful that Missouri’s Aug. 4 ballot measure in the primary election would succeed. At stake was health care for 230,000 residents. Passage would bring an estimated $1 billion a year of Missouri tax dollars back to the state, boosting the economy and keeping hospitals open, according to an analysis by Washington University in St. Louis.

For more information on the economic and health benefits of expanding Medicaid, visit [www.kff.org](http://www.kff.org).

*   Copyright The Nation’s Health, American Public Health Association