Bloomberg Law
Jan. 26, 2021, 10:13 AMUpdated: Jan. 26, 2021, 3:29 PM

Medicaid Expansion Ballot Measures Brewing in Three More States (1)

Christopher Brown
Christopher Brown
Staff Correspondent

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.

Six red states have expanded Medicaid eligibility by ballot initiative so far: Maine in 2017, Idaho, Nebraska and Utah in 2018, and Oklahoma and Missouri in 2020.

Medicaid is a joint federal-state health insurance program for low-income people that traditionally was focused on children, pregnant women, the elderly and the disabled. States were permitted under the 2010 Affordable Care Act to expand eligibility to include low-income able-bodied adults.

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.

The Covid-19 pandemic has shone a fresh spotlight on the need for health coverage, advocates say, but social distancing has also posed some logistical challenges for collecting signatures.

The three are among 12 states that haven’t expanded their Medicaid programs to include able-bodied adults earning up to 138 percent of the poverty level. The other nine are Alabama, Georgia, Kansas, North Carolina, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming.

Each of these states where a ballot measure is brewing has seen implacable opposition to expanding Medicaid from Republican-dominated Legislatures, supplemented by opposition—or, at best tepid support—from Republican governors.

But the success of the past ballot measures in other red states gives advocates confidence that more dominoes will fall.

“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.”

Around 830,000 people have gained Medicaid coverage as a result of ballot initiatives, according to The Fairness Project.

Expansion Push in Florida

An effort to bring a Medicaid expansion ballot measure to Florida for the 2020 election failed after the Legislature made changes to the ballot initiative process that drove up the cost of collecting signatures and raised the number of signatures needed for early stage review by the state Supreme Court.

The Legislature’s intervention—apparently a direct response to the Medicaid expansion measure—underscores the importance of the ballot initiative process as a tool to enact expansion in Florida, according to JoNel Newman, a professor at the University of Miami School of Law.

What’s unclear about the Legislature’s action is whether the Medicaid ballot measure can be revived under at least some of the old rules or must begin again under the new rules, Newman said.

“I do believe that they’re going to be able to restart this and get the funding to do it for the 2022 election,” Newman said.

The Florida Hospital Association expressed support for Medicaid expansion in a statement that fell short of saying it would back a ballot measure.

“We will always be on the front lines advocating for efforts that improve access to coverage, maintain appropriate funding for the cost of healthcare and services through state and federal safety net programs, and improve the quality of healthcare for everyone,” Mary Mayhew, the association’s president and CEO, said.

Two Drives in South Dakota

Rick Weiland, a leader of one of two separate drives in South Dakota to put Medicaid expansion before the voters, said he’s confident the voters will approve a measure if it can get on the 2022 ballot.

His group, Dakotans For Health, has begun collecting signatures after getting their ballot language approved late last year.

That makes South Dakota the first out of the gate among the states where ballot measures could appear in 2022.

Their target is around 36,000 signatures, but they’ll need to collect around 60,000 raw signatures to make sure they’ve collected enough that are deemed valid, he said.

The Fairness Project is backing a separate effort in South Dakota with the support of the South Dakota Association of Healthcare Organizations, the South Dakota Medical Association, the South Dakota Farm Bureau, and others.

Covid-19 has made the process of gathering signatures more challenging, Weiland said. “We’ve had to limit our circulators so far. We’ve been encouraging them to focus just on their own families and friends and neighbors,” he said. “But with the vaccine coming, we’re hoping we’ll be able to start looking to events where crowds of people are gathered.”

But Covid-19 has also driven home the importance of making sure people aren’t left without health-care coverage in a crisis, he said.

“Covid doesn’t discriminate, and has put a real strain on our health-care system and our health-care delivery,” he said. “This is something we should have done long ago.”

Mississippi Moves

The effort to get Medicaid expansion on the ballot in Mississippi is at an early stage, according to Roy Mitchell, executive director of the Mississippi Health Advocacy Program.

He expects to have ballot language before the secretary of state by the spring. But time is short—signatures will have to be collected by the end of 2021—and a lot hinges on whether the Mississippi Hospital Association comes on board, Mitchell said.

Support from MHA is particularly important because of the cost of mounting an effective campaign, he said. “Without their resources, it’s tough to have a robust public dialogue.”

Tim Moore, chief executive officer of the MHA, said the hospitals would probably back a ballot initiative if the Legislature fails to pass a Medicaid expansion bill in the current session.

“We’ve been trying to work with the Legislature for the last seven years, but we’re at the point now, after this pandemic and how it has hit the hospitals, where I think there would be a real appetite for going the initiative route,” he said.

Schleifer remains confident that expansion can prevail in Mississippi, where the Fairness Project will be involved. “We can see there’s a lot of enthusiasm in Mississippi,” he said. “All signs point to us having a vibrant campaign.”

Mitchell anticipates a vigorous pushback from opponents both inside and outside the state.

“With Medicaid expansion, it’s clear it will be expensive because of the opposition it will bring along,” he said. “We’re fully expecting to see outside groups come in and devote a lot of money against it.”

(Updated with comment from the Florida Hospital Association in the 17th and 18th paragraphs.)

To contact the reporter on this story: Christopher Brown in St. Louis at

To contact the editors responsible for this story: Fawn Johnson at; Karl Hardy at