Are Mississippi, South Dakota & Florida next on the Medicaid expansion list?

The ACA was originally designed with the intention that all documented Americans living in all 50 states (+DC) earning up to at least 138% of the Federal Poverty Level (FPL) would be eligible for Medicaid. Unfortunately, the 2012 NFIB v. Sebelius ruling by the U.S. Supreme Court stated that Medicaid expansion under the ACA had to be left up to each individual state.

This meant that each state had to decide, whether by legislation, executive order (depending on the state) or ballot initiative, whether or not to expand the low-income public health program or not. Under the ACA, any state which does so will have 90% of the cost paid for by the federal government, while the state has to pony up the other 10% of the cost.

On the one hand, this is the deal of a lifetime for the states--it means having hundreds of millions of dollars in federal funding pumped into their economy while also letting them provide healthcare coverage for a big chunk of their population. The net economic benefits far outweigh the 10% chunk that they have to pitch in (which admittedly can also still amount to hundreds of millions of dollars per year, depending on the state).

On the other hand...the ACA was passed by Democrats and signed into law by President Obama, so naturally a bunch of GOP-controlled states have adamantly refused to expand the program for the eighth straight year, because they simply can't stomach the idea of taking advantage of a law signed by him.

As a result, initially only around half the states expanded Medicaid while the other half didn't, leaving millions of low-income adults out in the cold...not being eligible for Medicaid but also earning too little to be eligible for a subsidized ACA exchange policy (exchange subsidies are currently only available to those earning 100 - 400% FPL, so anyone below the 100% threshold is SOL).

In response, over the past few years, the voters of some of those states have decided to take it upon themselves to force their legislators/governors to expand Medicaid anyway, via statewide ballot initiative campaigns:

• Maine: 2017 (though it didn't actually go into effect until 2019 due to the former GOP Governor refusing to implement it)
• Nebraska: 2020 (it went into effect in October though some elements are supposed to start in April)
• Utah: 2018 (though it didn't go into effect until 2020 after some absurd shenanigans by the state legislature & governor to attempt to partly undermine the program)
• Idaho: 2018 (though it didn't actually go into effect until 2020)
• Missouri: 2020 (it's scheduled to go into effect in July)
• Oklahoma: 2020 (it's scheduled to go into effect in July)

This leaves twelve states which are still refusing to budge: Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin and Wyoming, with a couple of caveats:

• Kansas has actually come within a single vote in the state legislature of expanding Medicaid, and the Democratic Governor supports doing so; it's conceivable that they'll finally get it into the endzone this cycle.

• Wisconsin didn't actually expand Medicaid to 138% FPL under the ACA, but has expanded it to 100% FPL for all adults using the standard federal/state cost-sharing arrangement, which is kind of odd because it means Wisconsin has to pay 40% of the cost for that population instead of just 10% for a larger population. The estimates vary, but as far as I can tell, the state is spending a good $250 million/year more to cover at least 12% fewer people than they have to.

In any event, it looks like the success of activists in pulling Medicaid expansion over the line by taking it directly to the people, especially in deep red states like Idaho and Oklahoma may continue going forward. Via Christopher Brown of Bloomberg News:

Health policy advocates in Florida, Mississippi, and South Dakota are pushing for Medicaid expansion at the ballot box to get around Republican opposition in the statehouse.

The three are the last remaining states where passing Medicaid expansion by ballot initiative is a possibility under the state constitution.

Unfortunately, it sounds like state laws regarding public ballot initiatives can't be done in the other nine states.

...Success in Florida, Mississippi and South Dakota would further demonstrate the popularity of Medicaid expansion even in Republican-dominated states and put pressure on lawmakers in other holdout states to follow suit. Expansion in Florida would add about 1.35 million to the state’s Medicaid rolls; in Mississippi, about 220,000; and in South Dakota, about 43,000.

Hmmm...these numbers are quite a bit higher than the Kaiser Family Foundation estimates from last week; they put it at 833,000 in Florida, 179,000 in Mississippi and 30,000 in South Dakota. It's also important to note that there are three different populations that these refer to: Those already eligible for Medicaid who haven't done so for whatever reason; those caught in the Medicaid Gap (childless adults earning less than 100% FPL) and those who may be enrolled in heavily subsidized ACA exchange policies at the moment (100 - 138% FPL).

“What we’re seeing is that the assumptions about health-care policy and public attitudes that were made 10 years ago are not true today,” said Jonathan Schleifer, executive director of The Fairness Project, a nationwide group that has been involved in Medicaid expansion ballot measure campaigns.

“It’s clear that people in red states want more health care, not less, even if politicians haven’t given up on trying to take away health care from people.”