Residents in Idaho, Nebraska, and Utah voted to expand Medicaid under the Affordable Care Act (ACA) Tuesday, granting health coverage to more than 300,000 low-income people.

Although all three states historically voted overwhelmingly for Donald Trump in the 2016 presidential elections, activists gathered enough signatures to put Medicaid on the ballot in each red state and residents managed to set partisan politics aside.

This means upwards of 62,000 people in Idaho, roughly 90,000 people in Nebraska, and more than 150,000 in Utah will soon have Medicaid insurance.

The number would have been higher had Montana residents also voted to continue its Medicaid expansion. Montana expanded Medicaid in 2016, but only until July 2019. Residents rejected a ballot to keep coverage for 100,000 people.


A Supreme Court ruling in 2012 allowed sates to opt out of expanding Medicaid under the ACA, and more than a dozen states run by Republicans have refused to expand the program to slight Democrats.

Under the ACA, Medicaid eligibility is extended to nearly all low-income people making below 138 percent of the federal poverty level, or $16,750 for an individual and $34,640 for a family of four. Millions gained coverage in states that expanded Medicaid. But states that did not left many in the “coverage gap” without an affordable option, meaning they earned too much to qualify for traditional Medicaid and not enough to qualify for subsidized insurance offered on the ACA marketplace.

Study after study shows the entire states loses when officials refuse to expand Medicaid for political purposes. Nearly 20 percent of low-income people living in states that did not expand Medicaid forwent medical care in the last year, compared to just 9.4 percent in states that did expand. Non-expansion states also saw more rural hospital closures than states that expanded Medicaid. Nineteen states that refused to provide care to more people by 2017 also forfeited $595.8 billion to $664.8 billion in federal funding over 10 years.

This chart below by the Center for American Progress (CAP) illustrates the harmful effects of not expanding most plainly. (Editor’s note: ThinkProgress is an independent news organization housed within CAP.)

Credit: Center for American Progress

“Outside of Washington, there’s a growing consensus that people want more health care not less,” executive director for the Fairness Project Jonathan Schleifer told reporters last Thursday. The Washington, D.C.-based group offered fiscal and logistical support to states looking to expand Medicaid by ballot.


The Fairness Project helped Maine become the first state to expand Medicaid by ballot last November. However, obstructionist Gov. Paul LePage (R) did everything he could to block the measure. Maine’s decision to elect Janet Mills (D) for governor on Tuesday may finally bring voters’ wishes of Medicaid expansion to fruition. Mills said during the campaign that she’d expand Medicaid “on Day 1.” (No state that expanded Medicaid by ballot this November is expected to see efforts to block those initiatives by local officials.)

Democratic gubernatorial wins in Kansas and Wisconsin also means Medicaid for hundreds of thousands of people. All together, Democratic wins in Maine, Kansas, and Wisconsin meaning 325,579 low-income people might finally have health coverage.

However, these states need more than a supportive governor to expand Medicaid under the ACA — they also need a supportive legislature (just ask North Carolina’s Democratic Gov. Roy Cooper). While the federal government’s financial share was 100 percent between 2014-2016, it phases down to 90 percent for 2020 and subsequent years, meaning state legislatures need to appropriate funds.

There also might be a catch for states that expanded Medicaid by ballot initiative: work requirements. Nebraska state Sen. John McCollister (R) told reporters last week that it’s “possible” that the legislature might add work requirements. When the Virginia legislature expanded Medicaid in May, they also approved work rules.