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As of June 2020, 14 U.S. states continued to reject Medicaid expansion, leaving many without an affordable healthcare coverage option.
Then COVID-19 hit—hardest among low-income, uninsured families, particularly Latinos.
In response to surging coronavirus cases, Oklahoma (11.1% Latino), the state with the second-highest uninsured rates, voted to expand Medicaid on July 1, 2020. A month later on Aug. 4, Missouri (4.4% Latino) also voted to expand Medicaid.
In these two states alone, roughly 430,000 low-income adults will be eligible for Medicaid.
“The American Heart Association supports expanding Medicaid because people living with low incomes are disproportionately affected by heart disease, hypertension, and stroke. Medicaid serves as the coverage backbone for the healthcare services these individuals need,” said Dr. Denise Hooks-Anderson, an assistant professor of family and community medicine at Saint Louis University and member of the American Heart Association, according to Voices for Healthy Kids.
There are still 12 states that haven’t expanded Medicaid─can ballot initiatives work there, too?
Medicaid Coverage Gap
In states that did not expand Medicaid, eligibility for the program is limited.
“The median income limit for parents in these states is just 40% of poverty, or an annual income of $8,532 for a family of three in 2019, and in nearly all states not expanding, childless adults remain ineligible,” according to Kaiser Family Foundation.
Without other financial assistance, 2.3 million families fall into a “coverage gap.” Their income is too high for Medicaid eligibility but below the Affordable Care Act (ACA) Marketplace premium tax credits.
The ACA Medicaid expansion passed in 2010 to provide a coverage option for people with limited access to employer coverage and limited income to purchase coverage on their own. Specifically, Medicaid eligibility was expanded to nearly all low-income individuals with incomes at or below 138% of poverty ($17,236 for an individual in 2019).
However, the 2012 Supreme Court ruling made Medicaid expansion optional for states.
Although 31 states plus Washinton DC had expanded eligibility for Medicaid over the next four years, inconsistent expansion across states has failed to address high uninsured rates among low-income adults nationally. Latinos, who saw their rate of health insurance coverage rise sharply since the ACA implementation, still have the highest uninsured rate among racial/ethnic groups (over 17%).
States with the largest uninsured populations are the states that have not expanded their Medicaid programs.
These 12 states have not expanded Medicaid, according to Kaiser Family Foundation status of state Medicaid expansion decisions:
- Alabama (4.6% Latino)
- Florida (26.4% Latino)
- Georgia (9.99%)
- Kansas(12.2% Latino)
- Mississippi (3.4% Latino)
- North Carolina (9.8% Latino)
- South Carolina (6.0% Latino)
- South Dakota (4.2% Latino)
- Tennessee (5.7% Latino)
- Texas (39.7% Latino)
- Wisconsin (7.1% Latino)
- Wyoming (10.1% Latino)
Texas, the state with the largest Latino population on this list, has the highest uninsured rates in the country and has not expanded Medicaid.
One third of Americans in the “coverage gap” today live in Texas; 17% in Florida; 11% in Georgia; and 8% in North Carolina.
Before Oklahoma voted to expand Medicaid in July 2020, it had the second highest uninsured rates.
Oklahoma and Missouri joined four other states in passing Medicaid expansion via ballot initiatives.
What Are Ballot Initiatives?
A ballot initiative is a form of direct democracy. Rather than relying on elected officials to propose and pass a policy, voters can propose and pass a policy.
These are some of the Yes/No proposals found on a ballot.
Twenty-six states allow ballot initiatives or referendum, and virtually every state allows ballot initiatives at the local level.
Although each state is different and has unique restrictions, there are essentially two steps to a ballot initiative.
- The first step requires a minimum number of registered voters sign a petition to put a proposed bill or constitutional amendment on a ballot for a public vote. In Florida, for example, proponents must collect signatures equal to 8% of the total number of votes cast in the last presidential election. In 2020, that means 766,200 registered voters must sign a petition to get a proposal on the ballot.
- The second step depends on if it is a direct initiative or an indirect initiative. For a direct initiative, the proposal goes directly to the ballot for a public vote. Some states require a simple majority public vote while others require a three-fifths supermajority. For an indirect initiative, the proposal goes to the legislature for some form of legislative action before going to the ballot for public vote.
Ballot initiatives have gained a lot of traction in recent years.
Ballot Initiatives for Medicaid Expansion
In 2014, a California union worker, Dave Regan, wrote a memo warning that declines in union membership could leave workers with fewer benefits. Regan proposed creating a nonprofit that would use the ballot initiative process to secure policies that would benefit workers.
In 2016, the Fairness Project started with ballot initiative campaigns to increase minimum wage in California and Maine.
In 2017, they joined Maine Equal Justice’s ballot initiative campaign to expand Medicaid in Maine through state statute.
“Ballots are an opportunity to put a question, in its undiluted form, in front of millions of people,” Regan said, according to the New York Times. “As opposed to traditional legislative work, where things get watered down to get out of committee, you end up with what you actually want when you use the ballot.”
After a win in Maine, the Fairness Project ran successful ballot initiatives in Nebraska, Utah and Idaho, also through state statutes.
However, some ballot initiatives have faced resistance when it comes to implementation.
For example, according to the New York Times:
- Governor LePage of Maine said he “would go to jail” before expanding Medicaid.
- The Utah government added a restriction that was not in the original ballot, requiring Medicaid enrollees to work, volunteer or search for work to secure coverage.
- Nebraska delayed enrolling patients into its Medicaid expansion for nearly two years.
Additionally, some state legislatures have changed requirements for ballot initiatives, making it more difficult for voters to use this democratic process.
The Fairness Project revised its strategy for its 2020 Medicaid campaigns in Oklahoma and Missouri.
The ballots asked voters to approve constitutional amendments rather than state statues.
Constitutional amendments prevent state lawmakers from modifying the proposal and can only be altered by another statewide referendum.
This offers more security at a time when some state lawmakers have threatened the democratic process.
But that means it requires more work from registered voters.
In Oklahoma, constitutional initiatives require gathering nearly twice as many petition signatures as statutory initiatives.
Pushing a Medicaid Ballot Initiative in Missouri and Other Non-Expanding States
In Missouri, many advocates helped push the Medicaid expansion ballot initiative.
A “Yes on 2” campaign was funded by $10 million in contributions from local hospital systems. They indicate the measure will funnel more federal money to keep rural hospitals open and create new healthcare jobs, according to the St. Louis Post-Dispatch.
“Our campaign couldn’t have happened without the work of countless Missourians across the state who have been working towards expanding Medicaid for years,” organizers of the Yes on 2 campaign said in a Facebook message on Aug, 4, the Dispatch reports. “From the bottom of our hearts, we thank everyone who has worked toward this moment.”
Beyond Housing, a comprehensive community development organization, also helped.
They used grantee funding from the Voices for Healthy Kids program at the American Heart Association to provide much-needed funding and technical assistance to help get the measure over the finish line.
“Many of the very people working on the front lines in restaurants, grocery stores, nursing homes and hospitals are also those who fall within the health insurance gap,” said Chris Krehmeyer, President and CEO of Beyond Housing, a nonprofit community development organization in North St. Louis County, according to Voices for Healthy Kids. “They earn too much to qualify for Medicaid but too little to afford private insurance. This win means they will now receive the health coverage they need to live healthy, productive lives.”
Who will lead the way in the remaining 12 states with no Medicaid expansion?
Florida is one of four states that allow constitutional initiatives. They have rejected Medicaid expansion.
The Fairness Project is focusing on Florida next. They will need to get 766,200 petition signatures to get the proposition on the ballot.
If you live in a state that hasn’t expanded Medicaid, contact your state leaders and tell them that access to care is vital for healthy outcomes in Latino and all children.