The Affordable Care Act’s Medicaid Expansion and the 2018 Elections – an Update

The Affordable Care Act’s Medicaid Expansion and the 2018 Elections – an Update


Voters in Idaho, Nebraska and Utah voted with strong majorities to accept the Medicaid expansion segment of the Affordable Care Act (ACA). In Wisconsin, Maine and Kansas the gubernatorial candidates opposed to the Medicaid expansion were beaten at the polls, opening the door for Medicaid expansion if legislators are in agreement.

Health coverage was the top issue for voters in the mid term elections and is one of the issues powering the Democratic take-over of the House due to Republican efforts to repeal the ACA. The flipping of the House from Republican to Democratic assures that the ACA will not be repealed in the next two years.

The Affordable Care Act expanded Medicaid to all uninsured US citizens with incomes less than 138 % of the federal poverty level ($16,754 for an individual). Texas, Florida and other states argued that the mandatory expansion of Medicaid was unconstitutional as an impermissible infringement on state’s rights and sovereignty. The Supreme Court held the expansion was optional with the states. The expansion opportunity was funded with 100% federal financial participation for three years, phasing down to a 90/10 by 2020. Many states (35 at latest count) leaped at the opportunity; others headed by the most conservative Republican Governors or state legislators were adamantly opposed. Thus we have an odd looking map where poor uninsured residents of Louisiana and Arkansas now have Medicaid coverage while their neighbors in Texas, Mississippi and Tennessee do not.

There are about 4.2 million uninsured low-income American citizens in the “coverage gap” – i.e. not eligible for the Exchanges because their incomes are too low and not eligible for the state’s existing Medicaid because their incomes are too high. Nearly 90% live in the South, and nearly three in ten live in Texas, one in six live in Florida and one in ten live in Georgia.

Maine voters took matters into their own hands and passed an initiative to expand Medicaid, but Governor Paul LePage has refused to implement the ballot initiative. Newly elected Maine Democratic Governor Janet Mills has pledged to implement the voter’s initiative. She will have a Democratic legislature due to sweeping victories.

Three states, Idaho, Utah and Nebraska just adopted the Medicaid expansion on the November ballot with handsome majorities. Half a million uninsured Americans may be eligible in the three states that just passed ballot initiatives. 

The Kansas legislature, dominated by Republicans, has passed the Medicaid expansion, but Governor Brownback vetoed it. Newly elected Democratic Governor, Laura Kelly is expected to sign it.

Newly elected Wisconsin Democratic Governor Tony Evers campaigned on the Medicaid expansion and will seek legislative approval to implement it from a heavily Republican Assembly and Senate.

One would think that many Republican politicians would want to accept the expansion and move on as this is now becoming a losing issue at the polls for them. In Georgia and Florida, its the best way to save their struggling rural hospitals, and in Texas it would give significant fiscal relief to counties who are responsible for indigent care funded with local property taxes.

Prepared by: Lucien Wulsin

dated: 11/7/18

Reflections on the Election

Illegal Immigration -- Just the Facts