How Medicaid broke through in three deep-red states, and could do the same in more

Luke Mayville helped pilot the “Medicaid Mobile” throughout Idaho, gathering signatures to force a statewide vote on Medicaid expansion under the Affordable Care Act.
(Mark Z. Barabak / Los Angeles Times)

Nebraska state Sen. Adam Morfeld, like healthcare advocates in many conservative states, was beginning to lose hope last year that his poorest constituents would ever get health coverage through the Affordable Care Act.

“After seven years of losing in the Legislature, it was apparent that passing Medicaid expansion just wasn’t politically feasible here,” he recalled.

Today, Morfeld and advocates in Idaho and Utah are celebrating the unthinkable: Voters in these three deeply red states backed ballot measures last week to expand Medicaid eligibility through the 2010 healthcare law, often called Obamacare.


The victories — which bring to 36 the number of states that have elected to expand Medicaid coverage — were the product of a model of political action that may become increasingly common across the country in coming years, particularly in traditionally Republican states.

The model relies on state ballot measures to circumvent state legislatures and governors’ offices dominated in many states by the most conservative wing of the GOP.

It taps into popular support for traditionally liberal ideas — such as extending health coverage to the poor and raising the minimum wage.

And the model brings together local activism with funding and strategic guidance from a national organization called the Fairness Project, a nonprofit advocacy group founded three years ago by a California labor union.

“Ballot initiatives allow us to put questions of economic fairness directly to the people,” said Dave Regan, president of SEIU-United Healthcare Workers West, who has called on organized labor to support broader political campaigns to support workers, even if they are not union members. “We are showing that people in Utah and Idaho and Nebraska want the same thing as people in California.”

Since 2016, the Fairness Project has backed 17 campaigns across the country, and won in 16.

In addition to this year’s Medicaid measures, the project helped lead successful passage in 2017 of a ballot initiative to expand Medicaid in Maine.

It has backed successful minimum wage campaigns in Arizona, Arkansas, California, Colorado, Maine Missouri, Washington, the District of Columbia and Massachusetts. In California and Massachusetts, lawmakers acted facing the prospect of a ballot campaign.

A successful 2018 measure will restrict payday lending in Colorado. And initiative campaigns or the threat of them have expanded paid family leave in Arizona, Michigan, Washington and the city of San Antonio.

The only setback was in Montana this year, where a flood of tobacco industry money helped defeat a measure to extend a Medicaid expansion set to sunset in 2019.

In Nebraska, Morfeld first heard of the Fairness Project last year while reading news reports about the passage of the Maine Medicaid measure. He immediately emailed the group asking for help.

Morfeld and others in the state, including healthcare groups and the liberal advocacy organization Nebraska Appleseed, had been arguing for years that expanding Medicaid would help working families who couldn’t afford health coverage.

The Affordable Care Act makes hundreds of billions of federal dollars available to states to extend Medicaid coverage to poor adults, a population that had been largely excluded. Medicaid eligibility was historically limited to vulnerable populations, such as low-income children, pregnant women, the elderly and people with disabilities.

“I come from the perspective that people can work hard but still need assistance,” said Morfeld, who was raised by a single mother who at times relied on government assistance to support her family.

That message never resonated in the state Capitol, where conservative state lawmakers and the governor said Nebraska couldn’t afford the expansion and shouldn’t provide government coverage for Nebraskans who could work.

But when the Fairness Project came to Nebraska shortly after Morfeld’s email and fielded a statewide poll, advocates discovered that state residents, in fact, were very sympathetic to the idea of helping their neighbors get coverage.

It was the same in Idaho and Utah, where broad public support for Medicaid convinced advocates that an initiative campaign could work.

In Nebraska, there was some precedent for this strategy. State voters had backed a minimum wage measure in 2014.

But in Utah, ballot measures had rarely been used, in part because collecting enough signatures was extremely expensive. “It just wasn’t something that was done,” said RyLee Curtis, campaign manager for Utah Decides, that state’s Medicaid campaign.

With funding from the Fairness Project, however, advocates in Nebraska, Idaho and Utah were able to fan out across their states and collect more than enough signatures.

They also honed a message that spotlighted the working people who would benefit, and they drew voters’ attention to the tax money the states were sending to Washington and not getting back.

That was particularly important for voters in the conservative states, said Maria Weeg, the general consultant to the Idaho campaign. “You have to root a campaign to the place where you are running,” she explained.

Equally important, the three Medicaid campaigns worked to ensure that Medicaid expansion was not seen as a Democratic Party issue.

That also proved critical. Surveys by Fairness Project shortly before election day showed solid support for the measures by Republican voters.

In Nebraska, GOP women supported it by 13 points, according to the polling.

At the same time, support for the Medicaid measure did not mean that Republican voters were willing to back Democratic candidates, as the GOP retained a strong hold on elected offices in all three states.

In the end, the three measures passed comfortably, with the Idaho initiative getting nearly 61% and the measures in Utah and Nebraska measure netting 53% .

Today the Fairness Project is already eyeing possible Medicaid expansion campaigns in other non-expansion states that allow ballot initiatives, including Florida, Mississippi, Missouri, Oklahoma, South Dakota and Wyoming.

“Our premise has been that people care more about the struggles of working families than their politicians do,” said Jonathan Schleifer, head of the Fairness Project. “By using ballot initiatives, we will continue to cut politicians out of the picture.”

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