More States Eying Medicaid Expansion Via Ballot Measures

February 12, 2021

Even before the House Energy & Commerce Committee included an incentive in their COVID-19 relief bill to get the hold-out states to expand Medicaid, health care advocates in several states were already working to extend the program through measures that could be on the ballot in the mid-terms.

Advocates in Florida and South Dakota have already gotten their ballot measures approved and are working to collect signatures. In Florida, 891, 589 signatures are needed by Feb. 1, 2022; South Dakota needs 33,912 sign-ons by Nov.8, 2021.

Mississippians in support of Medicaid expansion are also working on a ballot measure as legislative efforts in the state continue to fail.

Advocates in Mississippi also are reportedly in the preliminary stages of getting an expansion measure on the ballot that would cover an estimated 170,000 or so residents. Separately, the Mississippi Hospital Association is pushing a proposal, dubbed Mississippi Cares, that would use a Medicaid waiver to create a provider-sponsored plan to cover the expansion population.

Under the ACA, the federal government fully covered to costs of states that expanded Medicaid to residents earning up to 138% of poverty from 2014 to 2016 after which the match dipped to 90%. Most Democratic-led states expanded in the initial years. A few states expanded after 2016.

Over the past few years, residents in six GOP-learning states have defied their political leaders by supporting the expansion at the ballot box: Idaho, Utah, Maine, Nebraska, Oklahoma and Missouri. A recent survey by the Missouri Hospital Association (MHA) conducted just as the state legislators started their 2021 session found staunch support for expanding their state’s program, even from people who did not vote for it.

Of the 12 states that have not moved toward expansion, Florida, Mississippi and South Dakota are the only ones that can do so through a ballot initiative.

Meanwhile on Capitol Hill, the Energy & Commerce Committee is marking up a bill that encourages the hold-out states to expand by providing a 5% bump in federal matching funds for traditional beneficiaries. The extra dollars are available for two years after the bill is enacted and would only be available for a state that had not previously covered the expansion population.

Missouri and Oklahoma both plan to start enrolling additional people on July 1, so would presumably be eligible for the extra FMAP if the pandemic relief bill becomes law.

The Ballot Initiative Strategy Center backed the expansion push in Missouri and other states and is now partnering with advocates in Florida and supporting other states efforts.

The center hopes to help states throughout the cycle of an initiative -- spanning inception, policy development, research, coalition building and defense of the process from opponents’ attacks, explains BISC Executive Director Chris Melody Fields Figuerero.

“A core of our work this year is ensuring advocates have the tools, resources and training to be ready for 2022,” she says. Fields also notes that the signature gathering has been severely affected by the pandemic, and BISC has been working with state leaders on ways to ensure that the legally required signatures can be collected safely."

Jerry Vitti, founder and CEO of Healthcare Financial Inc., which connects people to public benefit programs, points out that Medicaid expansion is batting a thousand when it comes to state ballot initiatives.

“This speaks volumes about the overall pulse of the country,” he said. “Before COVID and the massive layoffs it caused, these expansion ballot initiatives might have failed. But now people, even in red states, are worried not just about COVID but about their overall health and that of their families,” he says. This shows that many GOP leaders have been misreading their electorate.

In additional to the expansion initiatives that could be on the ballot in 2022, Vitti notes that the Democratic governors in Kansas and North Carolina will be leading efforts to get their legislatures to expand Medicaid.

On Feb. 1, Kansas Gov. Laura Kelly (D) announced a plan to expand Medicaid and pay for it through fees levied on medical marijuana. -- Amy Lotven (