Voters in three states approved ballot measures that will make more people eligible for Medicaid, marking an expansion of health coverage after years of opposition to Obamacare by Republican lawmakers.

The ballot measures passed in Idaho, Nebraska, and Utah. That brings to 37 the number of states that have decided to offer Medicaid coverage to more low-income adults. Another plan that would have permanently extended Montana’s Medicaid expansion past June 2019 fell short, which means the expanded rolls for low-income people in that state will expire in July.

“This is just a very clear statement from the voters” on Medicaid expansion and an acknowledgment of its benefits after the program gained significant momentum in the last year, Jesse Cross-Call, a senior policy analyst at the left-leaning Center on Budget and Policy Priorities, told Bloomberg Law Nov. 7.

The sweep of Medicaid wins in GOP states is a sea change for Obamacare’s expansion that faced years of intense conservative opposition, including from the Trump administration. Their success at the ballot box also underscores that the health insurance program’s growth could be here to stay.

“If you ever wanted evidence of whether the ACA and the basic tenets of supporting affordable care for more people has wide public acceptance, this is it,” former CMS Administrator Andy Slavitt said ahead of Election Day. Slavitt ran Medicaid during the Obama administration.

Getting to Yes

Not everyone agrees. Voters tend to approve initiatives they see as free money, Thomas Miller, a resident fellow at the American Enterprise Institute, told Bloomberg Law.

“You have to think of the Medicaid expansion issue not in isolation, but as part of where the general direction is going on health care,” he said. Republican candidates had been on the defensive on Medicaid expansion instead of pushing their own policy ideas forward.

Now, the door’s moved “a little further” toward expansion “but not overwhelmingly,” Miller said.

The wins don’t necessarily signal the final form an expansion could take, he said. For example, some states could move forward with expansion waivers that include provisions the Trump administration would support such as work-for-Medicaid rules.

The Affordable Care Act opened up the safety-net health insurance program for the poor to parents and childless adults who made up to 138 percent of the federal poverty line or $16,753 for an individual. A U.S. Supreme Court ruling made the expansion optional: 33 states and Washington, D.C., have opted in so far. Those that didn’t expand cover only parents from 18 percent of poverty (in Alabama) to 105 percent (in Maine), according to the Kaiser Family Foundation.

About 84,000 people are estimated to be newly eligible in the three states, KFF figures show. These are individuals who make too much to qualify for Medicaid but not enough to receive tax credits in the health insurance exchanges created under the Affordable Care Act.

The results “create a lot of opportunities for health care and for getting people more coverage through the Medicaid expansion,” Cross-Call said. Comfortable wins in three red states could lead other non-expansion states to see voter referendums as a possible path forward to grow their programs.

The states’ decision now means at least two will have to figure out how to fund those newly covered people.

Medicaid currently covers more than 76 million people, including 15 million enrolled under Obamacare in states that have already expanded their Medicaid eligibility, according to the Kaiser.

The 2018 elections are “really speaking to the fact that health care continues to be a huge, huge political issue for voters in every election,” Matt Salo, head of the National Association of Medicaid Directors, told Bloomberg Law in the run-up to voting. Five years’ worth of evidence shows that Medicaid expansion does “an extremely effective, efficient job at getting high-quality, affordable health care to millions of people.”

“There are a lot of people in states who are sort of wondering, ‘Well, why not me?’” Salo said.

The Medicaid expansion process is similar to what happened at the inception of the Medicaid program 50 years ago, Salo said. About half of states initially opted in with a slow trickle of others following in the next five years.

“To me this is just kind of playing that dynamic out. It is taking a while for a lot of states to get there,” he said.

Maine Expansion

The new states voting for Medicaid expansion join Maine in passing the overhaul by popular vote. Backers of the initiatives hope they won’t run into the same problems as Maine, where defeated Gov. Paul LePage (R) had blocked implementation of the expansion.

Maine’s stalled expansion is likely to move ahead quickly with the election of Democrat Janet Mills to be governor.

Mills, the first woman ever elected governor of Maine, won 50 percent to Republican Shawn Moody’s 44 percent. Terry Hayes, an Independent, captured 6 percent of the vote.

Implementing Medicaid expansion in Maine was central to Mills’ platform.

Maine voted for Medicaid expansion at the ballot box in 2017 after LePage vetoed Medicaid expansion legislation five times since 2014. About 80,000 people are eligible for Medicaid expansion in the state.

LePage claimed Maine couldn’t afford the $50 million per year it would have to pay for the entitlement program.

Robyn Merrill, executive director of Maine Equal Justice Partners, which sued LePage over the Medicaid expansion, said Nov. 7 the group would remain focused until January on winning in court. She predicted that the election results “ bode well in Maine for Medicaid expansion and making health care more affordable.”

“If it looks like the ACA or at least the Medicaid expansion component of it is settled as the law of the land, then I think that gives a lot more cover to red states to pull the lever and say, ‘It’s OK for us to do this now,’” Salo said.

Pay-Fors in the Wings

The federal government picks up 90 percent of the tab for Medicaid expansions. It’s unclear how Nebraska and Idaho will fund their share. Nebraska might consider a cigarette tax, state Sen. John McCollister (R-Neb.) said on a recent conference call with the pro-expansion political action committee the Fairness Project, though the backlash in Montana gave him pause. He noted the fiscal impact would be “fairly modest,” between $20 million and $40 million in a budget of $4.5 billion.

Nebraska Republicans might impose requirements that tie Medicaid eligibility to employment as part of an expansion, McCollister said.

Utah’s Proposition 3 is set to fund the state’s estimated $78 million portion of the $846 million expansion cost by bolstering the state’s sales tax from 4.7 percent to 4.85 percent.