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Via the initiative and referendum process the ballot box provides an opportunity for voters to directly influence policy and state law. At the last general election Initiative 427 gave lawmakers an opportunity to directly see how their constituents felt about the expansion of Medicaid benefits to able-bodied adults. Medicaid is a program intended to provide basic health care for children, families, the disabled, and the elderly. Legislative bills attempting to expand Medicaid to able-bodied adults without children or disabilities have not passed during the past 6 years.
Initiative 427 passed statewide with 53% of the vote. Although a simple majority means the winner takes all, analysis of the voting results at the county and even precinct level shows a significant difference in Nebraska voters’ support of expanding Medicaid between voters in Nebraska’s eastern urban centers of Lincoln and Omaha and the rest of Nebraska.
For state senators outside of Lincoln and Omaha, the results on election day reinforced what constituents have been telling us when proposals to expand Medicaid came before the legislature. Despite a multi million dollar media campaign funded almost exclusively by out-of-state interests, the teacher’s union, and Omaha billionaires Warren Buffet and Walter Scott, Greater Nebraska voters demonstrated a firm opposition to expanding government benefits to able-bodied adults without children who have chosen not to obtain full-time work. It was the margin of support in Douglas, Sarpy, and Lancaster counties that pushed the measure into winning the statewide vote count.
Across District 38 none on the of the counties I represent voted in support of expanding Medicaid. Over 60% of the voters in Phelps, Kearney, and Nuckolls counties opposed to the measure while over 55% in Buffalo, Clay, Franklin, and Webster counties also opposed expansion. Even surrounding counties with demographics different then the predominantly rural counties I represent opposed Medicaid expansion including Adams, Hall, and Dawson counties. Despite allegations that the Legislature “failed to act”, local results of the election clearly show state senators who opposed expansion during prior years were accurately representing the voters in their districts.
In the political campaign leading up to election day, supporters of expanding Medicaid made a number of claims about the impact the additional entitlement and its associated costs will have, especially for rural Nebraska. As the expansion becomes law and new enrollees receive benefits, Nebraskans have the opportunity to examine and test the validity of those economic predictions.
For example, the impact of Medicaid expansion on the 64 critical access hospitals located throughout rural Nebraska was widely promoted. However, the vast majority of the Nebraska population is not served by these facilities. As the new enrollees sign up for Medicaid benefits we will be able measure the actual magnitude of the impact on rural Nebraskans and compare that against the costs and taxes paid.
We also will have an opportunity to compare point in time pre- and post-expansion to analyze the behavior and utilization patterns of new enrollees. For example, if the new recipients of the entitlement reduce or increase expensive emergency room usage and if they actually access preventative care that now will be free.
Another important metric to watch carefully will be the insurance coverage options provided by employers of part time employees. Expanded Medicaid now provides an incentive for employers to not offer insurance coverage to employees who might now be eligible for coverage at taxpayer expense. Analysis of those behaviors can provide insight into the impact of expanding entitlement programs to able-bodied working adults.
As the legislature develops legislation in the next session to enact Initiative 427, it would be advantageous to include mandatory reporting of relevant metrics by healthcare providers and new Medicaid enrollees. As experience has demonstrated with other taxpayer funded benefits, including the criteria for evaluation of the program’s success or failure and data collection is vital at the time of implementation.