FiveThirtyEight

Washington may have (mostly) stopped talking about the Affordable Care Act, but debates over the law are still raging in some states. Take Idaho. Just as the state was seeking to allow the sale of health insurance plans that don’t comply with the law, a group of activists was pushing to put Medicaid expansion on the ballot in November. On Monday, the activists announced that they had successfully gathered enough signatures. And polling suggests that Medicaid expansion has a real chance of passing.

In a state as red as Idaho, it’s no surprise that a majority of residents are opposed to the Affordable Care Act, the law that made Medicaid expansion possible. Under the ACA, the federal government began kicking in more than 90 percent of the cost of expanding the program to states that accepted the expansion, covering everyone earning less than 138 percent of the federal poverty line. (In Idaho, an expansion would cover an estimated additional 78,000 residents.) But even though Republicans nationwide tend not to like the ACA, a majority of them have favorable views of Medicaid, according to polling by the Kaiser Family Foundation. Even in states that haven’t expanded, a majority of people say they believe Medicaid is working well and they oppose reducing its federal funding.

So if a majority of Idahoans seem to like the program as is, what do they think about it growing to cover more people? Depends on how you ask them. In December of last year, a Boise State University poll of Idaho adults alerted respondents to the 78,000 low-income people who don’t have health insurance in Idaho, people who mostly fall in the Medicaid gap — too poor to qualify for subsidies on the health insurance marketplaces but too rich to qualify for Medicaid under current state rules. It did so, however, without ever mentioning the word Medicaid. It then asked, “Would you favor or oppose the governor and state legislature taking action to provide them with access to quality health care?” Three-quarters of respondents said they would favor the move.

In 2015, Dan Jones & Associates asked registered voters, “Do you support or oppose an expansion of federal Medicaid coverage in Idaho?” Sixty-one percent said they supported it. After the Republican-controlled Legislature declined to expand the program in 2016, 64 percent of Idahoans said they disagreed with the decision, including 49 percent of Republicans.

But support looked very different in a 2015 poll that described the people who would be covered under expansion as “working-age, nondisabled, mostly childless adults.” In this poll conducted by the Idaho Freedom Foundation, which opposes Medicaid expansion, just 39 percent supported the move. The group went on to ask how that support would change if a voter knew that “more than 1 in 3 people eligible for ObamaCare’s Medicaid expansion have spent time in prison or been involved in the criminal justice system,” and “Medicaid expansion could cause up to 16,000 able-bodied adults drop out of the labor force and shrink Idaho’s economy.” The majority of respondents said they’d be less likely to support expansion after hearing those statements. The language on the current ballot initiative is somewhat obscure, describing the effort as expanding Medicaid eligibility to “certain persons.” Given that, any support for the expansion could be susceptible to attack ads that will inevitably flourish during campaign season.

That may help explain why language was a divisive issue in Maine, where voters passed Medicaid expansion through a ballot initiative in November 2017. Gov. Paul LePage fought to label the expansion as “welfare” on the ballot, but it was ultimately categorized as “healthcare coverage.” Mainers had consistently shown majority support for Medicaid expansion before the vote — it’s hard to say whether that support would have changed if the program had been described as welfare or an entitlement, but LePage and the PAC he’s associated with sure thought it would. The initiative passed with 59 percent of the vote, but LePage has refused to implement it. On Monday, advocacy groups sued him over the issue.

In Idaho, Medicaid expansion has become an issue in the race to succeed Gov. Butch Otter, particularly in the Republican primary. U.S. Rep. Raúl Labrador has already said he’d consider overturning the measure if it passes, while Lt. Gov. Brad Little said he would abide by the will of the people. As in Maine, whether the expansion is actually implemented (or at least how quickly) could come down to the will of the legislators, even if the people are in favor.

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