This week, our In Focus section examines the 10 states that have not expanded Medicaid under the Affordable Care Act but where citizens can initiate a public vote on the issue. In November, nearly 60 percent of Maine voters approved a ballot initiative expanding Medicaid. Advocates in Idaho, Missouri, and Utah have filed paperwork to begin collecting signatures to place Medicaid expansion on the ballot in November 2018.
State laws affecting these citizen initiatives vary regarding the number of signatures required to place an issue on the ballot, the percent of votes needed for approval, the ability of the legislature to amend or appeal the measure after passage, and whether states allow initiated statutes or constitutional amendments. These variations in the law, along with other issues examined below, may affect the likelihood that Medicaid expansion ballot initiatives will be pursued and/or ratified.
Florida
In Florida, citizens can initiate a public vote on Medicaid expansion through a proposed constitutional amendment. Advocates attempted to place the issue on the 2016 ballot but gathered less than 1 percent of the necessary signatures. State law requires that proponents of a citizen-initiated constitutional amendment gather signatures equal to 8 percent of votes cast in the last presidential election. The state sets a high bar for votes needed to pass a ballot initiative: a 60 percent supermajority of votes is needed, and if the initiative imposes a new tax or fee, Florida requires a two-thirds supermajority. A 2017 poll by the University of Maryland found that 67 percent of Floridians favored Medicaid expansion compared with 64 percent nationally, as reported by the Miami Herald.
Idaho
Advocates of Medicaid expansion in Idaho submitted the necessary paperwork in October to begin collecting signatures to place the issue on the ballot in November 2018. For the issue to be placed on the ballot, state law requires proponents gather the number of signatures equal to 6 percent of registered voters as of the last general election. Only a simple majority of votes is needed for passage. A poll conducted by Boise State University in December 2016 found nearly 71 percent of Idahoans were “[in] favor of the state legislature taking action to provide access to quality health care for low income Idahoans who currently lack affordable comprehensive health coverage.”
Maine
Nearly 60 percent of Maine voters approved Medicaid expansion through a November ballot initiative. Governor Paul LePage immediately announced his intention to block expansion, stating “[his] administration will not implement Medicaid expansion until it has been fully funded by the Legislature at the levels DHHS has calculated.” While LePage lacks the power to veto a citizen-initiated statute that was altered by the legislature and presented to voters, he can cause funding problems and delay implementation. For example, citizen-initiated measures typically take effect 30 days after the vote, but if funding is insufficient, the law will take effect 45 days after the start of the next legislative session.
Mississippi
Mississippians can initiate a public vote on an issue through a proposed constitutional amendment. To place an issue on the ballot, state law requires proponents gather signatures equal to 12 percent of votes cast for governor in the last general election—a relatively high bar compared to other states. For a measure to pass, it must receive a majority of votes, and supportive votes must equal at least 40 percent of votes cast in the last election. Upon failure of an initiative, proponents must wait two years to place a measure on the ballot again.
Missouri
Advocates of Medicaid expansion in Missouri filed the necessary paperwork in September 2017 to begin collecting signatures to place the issue on the ballot in November 2018. Although Mississippians can initiate legislation as either a state statute or constitutional amendment, the initiative was filed as an initiated statute. Initiated statutes require collection of signatures equal to 5 percent of votes in the last gubernatorial election in two-thirds of congressional districts, compared to 8 percent for initiated constitutional amendments. While the legislature can vote to repeal both an initiated statute and amendment, repealing an initiated amendment requires subsequent public vote.
Nebraska
Nebraskans can initiate legislation as either a statute or constitutional amendment. Proposed statutes require proponents to gather signatures equal to 7 percent of registered voters, compared to 10 percent for proposed amendments. Because the requirement is tied to the number of registered voters at the signature filing deadline, proponents do not know the exact number of signatures required to get an issue on the ballot prior to submitting the signatures. A Democratic state senator indicated in November that he would introduce legislation to legislatively refer a constitutional amendment, which means the legislation must pass the legislature with a three-fifths majority, after which it would appear on the ballot. While the state’s unicameral legislature is officially non-partisan, members affiliated with the Republican party dwarf the number affiliated with Democrats, making the success of legislative referral unlikely.
Oklahoma
While Oklahomans can initiate legislation by proposed statute or constitutional amendment, state law makes it difficult for citizens to initiate legislation. For example, proponents have only 90 days to gather the required number of signatures. Critics, including a previous Oklahoma secretary of state, have complained about the lack of clarity surrounding the process. As a result, few initiated measures make it to the ballot in the state.
South Dakota
South Dakotans can initiate legislation by proposed statute or constitutional amendment. Proposed statutes require proponents to gather signatures equal to 5 percent of votes in the last gubernatorial election, compared to 10 percent for constitutional amendments. Passage requires a simple majority of votes.
Utah
Advocates of Medicaid expansion in Utah submitted the necessary paperwork in October to begin collecting signatures and holding public hearings in preparation for placing the initiative on the November 2018 ballot. The initiative will require the number of signatures equal to 10 percent of votes cast for president in the last election. After passage of a direct initiated statute (i.e., a statute that goes directly to the ballot after signature and not to the legislature), the legislature may amend an initiated statute with a simple majority vote. Seats in the Utah state Senate and state House of Representatives are overwhelmingly held by Republicans, which would likely reduce chances for Medicaid expansion.
Wyoming
While citizens of Wyoming can initiate legislation as a statute, the state sets a high bar for signature requirements—proponents must gather the number of signatures equal to 15 percent of votes in the previous general election. Additionally, after the initiative makes the ballot, state law requires that the majority of voters in the election vote for the measure, not just those voting on the measure. Upon failure of a ballot initiative, proponents cannot reattempt placing the issue on the ballot for five years.
Nine non-expansion states do not allow citizens to initiate ballot measures: Alabama, Georgia, Kansas, North Carolina, South Carolina, Tennessee, Texas, Virginia and Wisconsin.
Source: Ballotpedia, accessed November 2017; state laws.
