States throw voters under the bus in efforts to stop Medicaid expansion

Published on
June 1, 2021

The fight in the holdout states to thwart Medicaid expansion — or the mere threat of it — has reached a new low. Forget the “no” votes in state legislatures year after year that keep poor Americans from getting health care. Forget the specious arguments made by hostile legislators that the federal government will stop paying its share of Medicaid costs, leaving states holding the bag. Forget the 400-plus studies from think tanks and academics on the obvious benefits of medical care for all. Forget the voters in the holdout states who have approved expansion by way of ballot initiatives.

Apparently the next move is to try an end run around those voters. That’s what has happened in Missouri. Last summer, Missourians voted to expand Medicaid by a vote of 53% to 47%. This spring the legislature effectively said “no thanks” and refused to fund the state’s portion of the cost. Legal Services of Eastern Missouri has just filed a lawsuit challenging the legislature’s decision to withhold funds and asked the court to let newly eligible people enroll in the program and receive benefits. 

South Dakota and Mississippi have found a more direct way to thwart initiative movements like those in Missouri, Nebraska, and Oklahoma: Make sure they don’t happen.

In South Dakota, the first state to enact the initiative and referendum process in 1898, opponents changed the rules for initiative petitions that will make it much harder to put Medicaid expansion before the voters. In early March, when it appeared that an initiative petition to place Medicaid expansion on the ballot might have some traction, the South Dakota House and Senate passed a joint resolution that would effectively move the goal posts. The resolution will put a constitutional amendment on the June 2022 primary ballot that, if passed, would require Medicaid expansion to achieve a supermajority of 60% instead of a simple majority, since it would involve a state expenditure of more than $10 million. The state’s share of Medicaid funding could be up to $20 million annually, while the federal government is projected to spend about $300 million.

Primary elections in the state traditionally have a low voter turnout, and in South Dakota Democrats usually do not have contested primaries, all of which reduce the chances of passage, supporters of expansion fear.

During the floor debate on raising the threshold in the South Dakota House, one news outlet reported that Republican House Speaker Steven Haugaard of Sioux Falls, the state’s largest city, gave this reason for raising the threshold for voter initiatives such as Medicaid expansion, as reported by the Grand Forks Herald: “‘We’ve started out as a Republic,’ referencing the earliest days of U.S. history, when large swaths of the persons living in the country — women, enslaved persons, Native Americans— could not vote, Haugaard said. “‘Sadly, we’re tending in the direction of a democracy.’”  

South Dakota and Mississippi have found a more direct way to thwart initiative movements like those in Missouri, Nebraska, and Oklahoma: Make sure they don’t happen.

Rick Weiland, an official co-founder of Dakotans for Health, an advocacy group pushing for Medicaid expansion, told me “the legislature keeps making it harder and harder.” The arguments mirror those made by opponents in other states that are refusing to expand coverage. “You hear, ‘We don’t need any more welfare. We don’t need socialism or government-run health care.’ You hear it’s a government takeover,” Weiland told me. One big anti-expansion talking point insists that the folks who would benefit are lazy people who should get off the couch and get a job. But as in other states, many of the 42,500 uninsured people in South Dakota are working and have jobs, sometimes more than one to make ends meet.  A study published earlier this year by the Kaiser Family Foundation found that 76% of Montanans on Medicaid work, and 84% live in families in which a family member works. Advocates for expansion believe the numbers will be similar in neighboring South Dakota.

Expansion is dead in Mississippi, too. Its ballot initiative has died aborning. Expansion supporters in the state had begun to organize a drive to collect some 106,000 signatures needed to place the issue before the public. But the Mississippi Supreme Court dashed those hopes in mid-May when it invalidated the entire process for amending the state constitution by popular vote while striking down a medical marijuana initiative, effectively killing Medicaid expansion and any other ballot measure for now. A quirk in state law requires petition drive organizers to collect signatures from each of the state’s five Congressional districts. But in the 2020 census the state lost a seat, leaving only four districts. So as Justice James Maxwell wrote in his dissent, the court’s actions mean that “not only is this particular initiative dead, but so is Mississippi’s citizen initiative process.” Maxwell cited six attempts by legislators from 2003 to 2015 to fix the problem, adding, “None made it out of committee.” 

But the hurdles go beyond a technical hiccup in state law. Timothy Moore, president of the Mississippi Hospital Association, told me, “The economic arguments have not persuaded the legislature in 10 years. The fall back is that (expansion) would cost the state too much money. That came up every time.” He added, “We think it’s the right wing of the Republican party that’s the hardest to persuade. There are enough supporters on the floor. It’s the leadership that is stopping it.”

South Dakota House Speaker Steven Haugaard (R-Sioux Falls) gave this reason for raising the winning threshold for voter initiatives such as Medicaid expansion: “We’ve started out as a Republic. Sadly, we’re tending in the direction of a democracy.”  

Then there’s Texas, the state that has the most uninsured who would be eligible for coverage under Medicaid expansion — some 1.4 million people. Expansion has come up in the last five legislative sessions going back to 2013.  Supporters thought they might have had a shot this spring because nine Republicans had signaled support. But the Texas House would not give it a hearing.  A Democrat tried to attach the measure to a budget bill, but that failed too. “I’ve heard some capital insiders speculate that the governor’s office approached the nine Republicans and offered carrots and sticks, and eight of the nine voted it down, so it’s dead, dead, dead,” said Elena Marks, president and chief executive officer of the Episcopal Health Foundation in Houston.

Also blurring the prospects in Texas is the state’s uncompensated care pool, a sum of money included in the state’s federal Medicaid waiver to cover the hospital bills of uninsured. The Trump administration approved a 10-year extension of the waiver five days before Trump left office. The Biden administration, however, revoked the waiver for not following procedures, such as skipping the required public comment period. The state is refiling for approval. Marks worries the state’s hospitals may not strongly support Medicaid expansion going forward if they’re guaranteed a large pool of money for uninsured care regardless. “The governor is trying to pitch this as you don’t need (Medicaid) expansion because you’re going to get this money,” she told me. “Money for uncompensated care acts as a safety valve. If the dollars are big enough, I fear hospitals will feel comfortable with high rates of uninsured.”

If anything, the protracted fight over Medicaid expansion signals that it’s time for out-of-the-box thinking. Several years ago journalist Merrill Goozner, editor emeritus of Modern Healthcare, suggested that one way to increase coverage under Medicaid might be to federalize the program. Take the states out of the funding equation and remove their ability to say no. One quarter of state budgets, on average, now go to fund Medicaid and relieving them of that obligation would provide money for other needs. As he wrote in Democracy Journal, “We could create a unified federal program that covers nearly 40% of the population that doesn’t get its health insurance through employers” and “there’s no shortage of good ideas on how to fund it.”

If expansion continues to fail in the 12 states, perhaps it’s time to think about other ways to cover the millions still barred from coverage. How long will we allow our polarized political system to simply write off the very poorest Americans who happen to live in the wrong state?

Veteran health care journalist Trudy Lieberman is a contributing editor at the Center for Health Journalism Digital and a regular contributor to the Remaking Health Care column.

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