2018 Elections: Key Medicaid Issues to Watch

Medicaid provides health insurance coverage for more than 76 million Americans, supplies funding for safety-net providers, and is the largest source of federal revenues for states. At this time last year, Congress was debating repeal and replace of the Affordable Care Act (ACA) as well as more fundamental changes to Medicaid financing. While federal legislative changes to Medicaid did not pass in 2017, the outcomes of the 2018 elections will shape program changes at both the state and federal levels of government. Our state-specific fact sheets provide background information about Medicaid and the upcoming elections.

Three states (Idaho, Nebraska and Utah) have November ballot initiatives to implement Medicaid expansion. Voters in Idaho, Nebraska and Utah will vote on a measure on the November ballot that would adopt the ACA Medicaid expansion to 138% of the federal poverty level. In addition, Montana voters will vote on a measure on the November ballot that would eliminate the state’s June 2019 expansion program sunset date and raise tobacco taxes to fund the state’s share of expansion costs. In Maine, the Medicaid expansion was adopted through a ballot initiative in November 2017. After resisting implementation of the expansion, the Governor complied with a Maine Supreme Judicial Court order to submit an expansion state plan amendment (SPA) to the federal government in September 2018, but he accompanied it with a letter asking CMS to reject the SPA. Ultimately, the outcome of implementation of the expansion in Maine will fall to the state’s next governor.

Gubernatorial races in 36 states could have implications for the direction of state Medicaid programs. Changes in the composition of state legislatures could also have implications for Medicaid. For example, such changes in Virginia made Medicaid expansion possible. Some Democratic candidates in toss-up non-expansion states, including Florida, Georgia, Kansas and Wisconsin, are running on expansion. In addition, state elections could affect the adoption of work requirements in Medicaid. For example, in Michigan, the outgoing Republican governor signed legislation to impose a work requirement in Medicaid, but the newly elected governor could move forward with or work to oppose CMS approval and implementation of these requirements.

Federal elections could affect Medicaid’s future. The elections could shift the composition of Republicans and Democrats in the Senate and the House and influence whether Congress considers legislation related to the ACA. These legislative efforts could have implications for the ACA Medicaid expansion and Medicaid financing caps. A preview of such debates appears in Senate races in Missouri, North Dakota, and West Virginia, where Democratic incumbents are running on protections for people with preexisting conditions. The Republican challengers in both Missouri and West Virginia are state attorneys general who have signed onto Texas v. Azar, another legal challenge to the ACA.