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Idaho, Nebraska, and Utah vote to expand Medicaid

More than 300,000 low-income Americans are on the brink of gaining coverage.

Bay Area Activists Protest Cuts To Medicaid
Protestors carry signs as they demonstrate against proposed cuts to Medical and Medicare outside San Francisco city hall on September 21, 2011.
Justin Sullivan/Getty Images

Three states voted Tuesday to expand their Medicaid programs, which will extend coverage to an estimated 325,000 low-income Americans.

Voters in Idaho, Nebraska, and Utah passed ballot initiatives that would commit their states to participating in the Affordable Care Act’s expansion of Medicaid to all residents who make less than 133 percent of the poverty line (about $16,000 for an individual or $33,000 for a family of four).

In Idaho, the Medicaid expansion passed by an especially large margin, with 61 percent in favor and 39 percent against. The Nebraska expansion passed with a tighter margin: 53 percent of voters in favor, and 47 percent against. And in Utah, where the vote still hasn’t been certified by the state, but NBC projects a win, the proposition leads with 54 percent of the vote.

Separately, voters in Montana appear to be rejecting a ballot to continue their Medicaid expansion (its funding is set to sunset this summer). With 96 percent of the vote in, 54 percent of Montanans have voted against the measure, which would have also increased cigarette taxes. That program has enrolled 129,000 low-income Montanans since the expansion began in 2015 but will end later this year if the legislature doesn’t step in and provide more funding.

Last year, Maine became the first state to approve Medicaid expansion by ballot initiative, though its Republican governor has stood firmly in the way of implementation.

These new victories show that more conservative states are slowly warming up to this part of Obamacare. It also demonstrates that health law advocates have a new strategy for expanding coverage in states where the governor and state legislature are reticent to do so: taking their case straight to the voters.

In red states, Medicaid expansion is more popular than Obamacare

Eight years after the Affordable Care Act passed, Americans still remain bitterly divided over the health care law. Polls find that Republicans generally say they don’t like the law, while Democrats favor it.

But the polling looks really different when you focus on Medicaid expansion, which tends to be much more popular than the overall law.

A poll from Boise State University last summer asked Idahoans about the two issues. It found that just 35 percent of voters favored the Affordable Care Act, but 75 percent supported the Medicaid expansion ballot initiative.

Separate polling in Utah found that most voters who describe themselves as “somewhat conservative” were supportive of the Medicaid expansion.

This is, in part, what drafters of the Affordable Care Act have expected: With President Barack Obama out of office, certain Obamacare programs will become less associated with him — and become less polarizing, too.

Organizers are now eying the next states they could target with a similar strategy.

The nonprofit Fairness Project worked with state activists in all four states that voted on Medicaid expansion this year and plans to continue the effort. People from the project are now eying six states where they believe they could put Medicaid on the ballot in the near future, but they have not yet released details.

“After spearheading this year’s campaigns, The Fairness Project is exploring the viability of races in all six states that have ballot processes but haven’t expanded Medicaid,” a statement provided to Vox said. “Our track record has shown that even in red states we can turn enthusiasm into votes into health care.”

Medicaid expansion is associated with better access to care and better outcomes

What happens when states expand Medicaid? A growing body of research finds that low-income Americans start getting more access to health care and experience better health outcomes as a result.

“In terms of what happens to patients, we have 40-plus studies looking at this over the past decade,” says Benjamin Sommers, a health economist at Harvard who studies Medicaid expansion. “It makes a major difference in patients’ ability to access health care, to pay their bills, and in many studies, we see improved health outcomes too.”

States that expanded Medicaid tend to see their populations having greater access to a wide array of health care services, from primary care to substance abuse treatment to surgery. Patients report having an easier time paying their medical bills after gaining coverage through Medicaid and carry less debt.

National Bureau of Economic Research

And while its still early, researchers have found better health outcomes in the states that have expanded Medicaid. One study in the Journal of American Public Health, for example, found that states expanding Medicaid have seen a greater decline in infant mortality than those who do not participate in the program. Another that Sommers worked on showed that Medicaid actually saved lives for among patients with kidney disease who are starting dialysis.

Studies that ask patients to describe their own health find significant increases in people reporting themselves to be in “excellent health” after Medicaid expansion, too.