Big wins for Medicaid: Voters in Idaho, Utah and Nebraska approve expansion

The states that comprise the Great Plains and Mountain West are defined by values that perhaps arose from the rugged, inarable land itself: self-reliance, individualism, and resourcefulness. Similar values ground the Republican Party’s current healthcare platform; leaders often speak of “choice,” “flexibility,” and “independence.”

These values, one might argue, are what led most of those states to oppose Medicaid expansion when it first became an option in 2014. Indeed, most are red states, with just a few exceptions.

But those states are also defined by a strong sense of community and helping others. Perhaps that’s part of why four let voters decide on the expansion this year: Idaho, Nebraska, Utah, and Montana.

The initiatives passed in three of the four. Though the states have much in common, they are unquestionably distinct.


Voters approved Medicaid expansion by an overwhelming 61-39 margin.

The expansion will extend healthcare to 62,000 Idahoans, according to Reclaim Idaho, a group that campaigned in favor of it. The state itself placed the estimate even higher, with 91,000 more residents covered by 2020, the first coverage year for expansion enrollees.

Idaho’s expansion will cost the state $10.4 million in its first year, according to the Department of Health and Welfare’s report. It is also expected to receive $179 million from the federal government, bringing the total cost of the expansion to just under $190 million in 2020.

Over the next decade, it will cost the state a cumulative total of $105 million.

Idaho Governor Butch Otter surprised many when he announced his support for the expansion just one week before the election. Earlier this year, Otter attempted to permit the sale of health plans that didn’t comply with the ACA; CMS eventually blocked that move.


Nebraska voters approved Medicaid expansion by a slightly slimmer margin: 53-49.

Legislation authorizing expansion failed in Nebraska six times, each time either failing to pass in the unicameral legislature or being vetoed by the governor. One might say this attempt was lucky number seven. 

Economists at the University of Nebraska released a report this year analyzing the effects of a potential expansion in the state. More than 87,000 Nebraskans would gain coverage by 2021, they found. If implemented July 1, 2019, the expansion would cost the state $19.8 million in fiscal year (FY) 2019-20, $32.2 million in FY 2020-21, and $38.8 million in FY 2021-22.

Unique challenges in the state made it a prime candidate for expansion, the report said. With the population concentrated in the easternmost edge of the state, it is difficult for rural communities in the bulk of the state to receive care. And many of its rural residents have experienced injuries on the job: its worker injury and fatality rates are higher than those for the nation overall. 

In addition, only 42.6% of Nebraska’s private employers offer healthcare coverage.

By the end of October, the speaker of Nebraska’s unicameral legislature believed it would pass “fairly handily.”


Utah voters approved expansion with 53% of the vote.

Some 150,000 Utahns are expected to gain access to care, according to Utah Decides, a pro-Prop 3 advocacy group. The state will receive more than $800 million from the federal government to fund the expansion, and the state’s portion will come from a 0.15% sales tax increase.

The campaign for expansion in Utah was marked by faith-based messages perhaps more than in any other state. While the Church of Jesus Christ of Latter-day Saints didn’t take an official position on the initiative, some individual church leaders did, and some leading the effort on the ground pointed to their faith as a reason for their support.

Despite being known as a conservative state, only one group fought against Prop 3, the Utah chapter of Americans for Prosperity.

Over the summer, the state asked CMS through a §1115 waiver to expand Medicaid eligibility to adults with income up to 100% of the federal poverty level. That application is pending.


Montana already expanded Medicaid, but a ballot measure that would have continued funding the program by increasing taxes on tobacco products failed with 55% voting against it.

Montana’s proposition differed slightly from the other three. The Treasure State expanded Medicaid through a §1115 waiver in 2015, with coverage beginning in 2016. But that waiver was designed to last only through 2019, unless the state’s legislature decides to renew it.

It hasn’t—at least not yet—so health advocacy groups created a ballot initiative, I-185, that would sustain it through a tax on tobacco products, including e-cigarettes.

The tax would increase the cost of a pack of cigarettes by about $2. Predictably, the tobacco industry spent $17 million combating the measure, more than twice what the healthcare industry, including the Montana Hospital Association, spent advocating for it.

Healthy Montana, the group that led the campaign for I-185, said the measure would prevent nearly 100,000 Montanans from losing coverage. Montana has not increased its tobacco tax in 13 years, the group noted.

The expansion is also good for Montana’s economic health, Healthy Montana said. A report the University of Montana released in April found that the expansion generated thousands of healthcare jobs (nearly 1% of all employment in the state), $1.2 billion in personal income, and $2.6 billion in sales in the state between 2016 and 2020.