November 7, 2017

The health care issues at stake in Tuesday's state elections

Daily Briefing

    Voters on Tuesday will weigh in on state ballot initiatives and gubernatorial and statehouse races that could determine whether more states will expand Medicaid under the Affordable Care Act.

    In a state of reform: Profiles of innovative state-level Medicaid transformation

    Maine voters consider Medicaid expansion ballot initiative

    Maine voters will cast their votes on a ballot initiative (Maine Question 2) that would require the state to expand Medicaid. Medicaid expansion advocates fought to get the initiative on the ballot after Gov. Paul LePage (R) vetoed several bills passed by the state Legislature to expand Medicaid in the state. Roughly 80,000 Maine residents could gain Medicaid coverage if the state expands the program. According to Maine Public Radio, the federal government under current law initially would cover 94 percent of the expansion's costs, but that share would gradually decrease to 90 percent by 2020.

    Even if Maine voters approve the ballot initiative, LePage could still block or delay the expansion, according to Harvard University's Emma Sandoe. Sandoe notes that the ballot requires the state to submit an expansion plan to HHS within 90 days of its effective date, but she says "in Maine the governor has the ability to declare that there is not enough funding available and the initiative must go back to the legislature for approval within 45 days of the start of the session."

    However, Axios' "Vitals" reports that LePage will not be able to seek re-election next year because of the state's term limits for the office, which could leave the ultimate decision of whether or not to expand the state's Medicaid program to his successor.

    Still, expansion supporters say if the ballot initiative is successful in Maine, it could serve as a model for other states that have not yet expanded Medicaid.

    Medicaid expansion in Va. could hinge on statehouse, governor races

    Voters in Virginia Tuesday will be able to weigh in on Medicaid expansion in a less direct manner through both the governor's race and elections for all 100 seats in the state's House of Delegates.

    Republicans currently control 66 seats in the Virginia House, and the state Legislature has repeatedly blocked outgoing Gov. Terry McAuliffe's (D) attempts to expand Medicaid. According to Vox, Medicaid expansion could become a viable option in the state if residents elect Democrat Ralph Northam, the state's current lieutenant governor, over Republican Ed Gillespie, to be the state's next governor, and Democrats win a majority in the state House. While polling experts say it is unlikely that Democrats will be able to completely retake the state House, Vox reports that winning even a few seats could better position Democrats to win a majority in 2019.

    According to "Vitals," an estimated 400,000 Virginia residents could gain Medicaid coverage if the state expands the program.

    Ohio voters to weigh in on Rx drug spending

    Meanwhile, Ohio voters on Tuesday will weigh in on a ballot initiative that would require state health programs to purchase prescription drugs at prices equal to or below those paid by Veterans Affairs (VA), Kaiser Health News reports. According to KHN, VA typically purchases drugs at steep discounts when compared to other payers.

    The initiative, called the Drug Price Relief Act (Ohio Issue 2), is intended to curb state spending on prescription drugs. Supporters of the measure have estimated that it could save the state about $400 million.

    However, critics of the measure say it would be difficult to implement, it could limit patients' access to drugs, and it might not result in savings. For instance, an analysis by the Ohio Office of Budget and Management concluded that it was not clear whether the measure would generate savings.

    According to KHN, the ballot initiative if approved could serve as a model for other states, though Jane Horvath, a senior policy fellow at the National Academy for State Health Policy, notes that California voters last year rejected a similar measure (Baker, "Vitals," Axios, 11/7; Leonard, Washington Examiner, 11/7; Mistler, "Shots," Maine Public Radio/NPR, 11/7; Luthra, Kaiser Health News, 11/7; Kliff, Vox, 11/6; Stein, Vox, 11/2; Wasserman, NBCNews, 11/6).

    Where the states stand on Medicaid expansion

    The Supreme Court ruling on the Affordable Care Act (ACA) allowed states to opt of the law's Medicaid expansion, leaving each state's decision to participate in the hands of the nation's governors and state leaders.

    The Daily Briefing editorial teams have been tracking where each state stands on the issue since the ruling, combing through lawmakers' statements, press releases, and media coverage. In this latest iteration of our Medicaid map, we've determined each state's position based on legislative or executive actions to expand coverage to low-income residents using ACA funding.

    Get the Map

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