Idaho Proposition 2, Medicaid Expansion Initiative (2018)

Elections in Idaho, 2018

• General election: Nov. 6
• Voter registration deadline: Oct. 12
• Early voting: Oct. 22 - Nov. 2
• Absentee voting deadline: Nov. 6

• Online registration: Yes
• Same-day registration: Yes
• Voter ID: Photo ID required
• Poll times: 8:00 a.m. to 8:00 p.m.

---

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Idaho Proposition 2
Election date November 6, 2018
Topic Healthcare
Status Approved/Altered
Type State statute	Origin Citizens
List of Idaho measuresIdaho Proposition 1Idaho Proposition 2Submit

Idaho Proposition 2, the Medicaid Expansion Initiative, was on the ballot in Idaho as an initiated state statute on November 6, 2018. It was approved.

A yes vote was a vote in favor of expanding Medicaid eligibility to those under sixty-five years old whose income is 133 percent of the federal poverty level or below and who are not eligible for other state insurance coverage, which would effectively increase the coverage level to 138 percent under the provisions of the Affordable Care Act.

A no vote was a vote against expanding Medicaid eligibility in Idaho under the Affordable Care Act, thereby leaving current levels of coverage in place.

Aftermath

Legislative alteration

See also: Legislative alteration

Senate Bill 1204 was passed in the state legislature on April 5, 2019, and signed by the governor on April 9, 2019. SB 1204 was designed to require Medicaid recipients to do the following:

• Work at least 20 hours per week or earn wages equal to or greater than the federal minimum wage ($7.25 per hour as of 2019) for 20 hours per week or participate;
• Participate in a work training program for 20 hours per week;
• Be enrolled at least half-time in postsecondary education or other education program;
• Satisfy the work requirements with a combination of working, volunteering, or participating in a work program for 20 hours per week; or
• Comply with the requirements of the work programs under the temporary assistance for needy families (TANF) or supplemental nutrition assistance program (SNAP).

SB 1204 includes some exemptions for the work requirement. Click here to read SB 1204.

Lawsuit

Brent Regan v. Idaho Secretary of State Lawerence Denney

  

Lawsuit overview
Issue: Whether the initiative unconstitutionally delegates too much power to the federal government and the state Department of Health and Welfare
Court: Filed in Idaho Supreme Court
Ruling: Ruled in favor of defendants, Proposition 2 is legal
Plaintiff(s): Kootenai County Republican Central Committee chairman and head of the Idaho Freedom Foundation’s board of directors, Brent Regan	Defendant(s): Idaho Secretary of State Lawerence Denney
Plaintiff argument: The initiative violates the constitution by delegating too much power to the federal government and the state Department of Health and Welfare	Defendant argument: The lawsuit is unfounded because Medicaid expansion under the initiative does not remove the state's ability to opt in or out and does not cede power to the federal government

  Source: Post Register

On November 21, 2018, Brent Regan, Kootenai County Republican Central Committee chairman and head of the Idaho Freedom Foundation’s board of directors, filed a lawsuit in the Idaho Supreme Court seeking to block Proposition 2.

The filing stated, "In essence, Proposition 2 has delegated to the federal government for its future determination Idaho’s percentage of financial contribution and therefore Idaho’s share of the costs Idaho will be forced to pay for Medicaid expansion."

In court arguments on January 29, 2019, Bryan Smith, an attorney for Idaho Freedom Foundation, said, "When they voted for that, they also understood that the government was going to pay 90 percent. That's what they understood. The federal government can change that, and if they change that, then the people just voted for something that becomes different."

Initiative sponsor and organizer Luke Mayville said "We view the lawsuit as a political stunt. It’s unfortunate to see the Idaho Freedom Foundation continue to play political games with people’s health care. Medicaid expansion was approved by Idaho voters with over 60 percent of the vote. The IFF has already lost the argument with the voters and now they’re almost certain to lose the argument with the courts."

Assistant Chief Deputy Attorney General Brian Kane said, "There is simply no delegation to the federal government. This petition [the lawsuit against Proposition 2] is without legal foundation because no cogent legal theory has been advanced, procedurally or substantively. [...] You can't force states to make that change. The state of Idaho has consistently approached any change within Medicaid as requiring the state to opt in."

On February 5, 2019, the Idaho Supreme Court ruled that Proposition 2 was legal. Chief Justice Roger Burdick, writing for the majority of justices in dismissing the lawsuit wrote, "If we were to accept Regan’s argument that any reference to a federal statute delegates lawmaking authority to the federal government, then many of Idaho’s statutes would be unconstitutional, and in fact, the option of any cooperative federal-state program would be curtailed."

Legislative alteration context

See also: Legislative alterations of ballot initiatives and Legislative alteration rules

From 2010 through 2018, 97 initiated state statutes and two initiated ordinances in D.C. were approved by voters. Of these 99 total initiatives from 2010 through 2018, 28 were repealed or amended as of April 2019. The states with the most total cases of legislative alterations of initiatives approved since 2010 were Maine—with four initiatives altered out of eight approved—and Colorado and Oregon—each with three initiatives altered out of five approved. Among initiatives approved from 2010 through 2018, marijuana was the topic that drew the most legislative alterations, with eight initiatives. Other topics addressed by legislatively altered initiatives included elections and campaigns, term limits, education, business regulation, law enforcement, minimum wage, taxes, and gambling.

The rate of legislative alteration was 13 percentage points higher for initiatives approved in 2016 and 2018 than initiatives approved from 2010 through 2015.

Legislative alteration rates
Year span	# approved	# altered	Alteration rate
2010 - 2024	175	30	17.14%
2016 - 2018	56	20	35.71%
2010 - 2015	43	9	20.9%

Click here for information about all legislative alterations of initiatives approved since 2010.

Election results

Idaho Proposition 2
Result		Votes	Percentage
Yes		365,107	60.58%
No		237,567	39.42%

Results are officially certified.

Source

Overview

Obamacare and Medicaid

As of 2018, Medicaid was a government program that provides medical insurance to groups of low-income people and individuals with disabilities. The Affordable Care Act (ACA), also known as Obamacare, provided for the expansion of Medicaid to cover all individuals earning incomes up to 138 percent of the federal poverty level. In 2012, the U.S. Supreme Court ruled in NFIB v. Sebelius that the federal government could not withhold funds from states that refused to expand Medicaid. The ruling had the practical effect of making Medicaid expansion optional for states. As of March 2018, 18 states, had chosen not to expand Medicaid.

Initiative design

Proposition 2 was designed to require the state to amend it's Medicaid plan to expand Medicaid coverage to more individuals in the state of Idaho pursuant to the Affordable Care Act (ACA). Proposition 2 expanded Medicaid eligibility to those under sixty-five years old whose income is 133 percent of the federal poverty level or below and who are not eligible for other state insurance coverage. Under the ACA, however, 5 percent of income can be excluded when calculating eligibility, which means the effective threshold is 138 percent of the federal poverty level under Proposition 2. The ACA, also known as Obamacare, provided federal funds to states that elect to expand Medicaid. States were required to provide a percentage of funds for expansion in 2017 and each year thereafter to receive the federal funds. From 2014 to 2016, the federal government covered 100 percent of the costs of state expansion of Medicaid. In 2017, the total cost that the federal government financed decreased to 95 percent. The ACA was designed to decrease the amount the federal government covers to 94 percent in 2018, 93 percent in 2019, and 90 percent in 2020 and subsequent years.

As of 2018 in Idaho, Medicaid coverage was available to pregnant women with incomes less than 138 percent of the federal poverty line and for parents with incomes less than 50 percent of the federal poverty line. Coverage for adults without children was not available under Idaho's Medicaid plan.

State of the ballot measure campaigns

Two committees registered to support Proposition 2: Idahoans for Healthcare and Reclaim Idaho. Together, the committees had raised $1.78 million and had spent $1.77 million. The largest donors were The Fairness Project, St Luke's Health System, and Saint Alphonsus Regional Medical Center.

The Work, Not Obamacare PAC was formed as a miscellaneous committee. Fred Birnbaum—vice president of Idaho Freedom Foundation, an organization with which the treasurer of Work, Not Obamacare PAC was associated—said that the PAC would be working to oppose Proposition 2. The committee had raised $59,930 and had spent $65,713. The largest donors were Daniel Brockett, Doyle Beck, and Regan Properties LLC.

What states voted on measures related to Medicaid expansion in 2018?

In November 2018, voters in Idaho, Montana, Nebraska, and Utah decided ballot initiatives concerning Medicaid expansion and the funding of expanded Medicaid coverage. In January, voters in Oregon approved Measure 101, thereby upholding 2017 legislation to provide funding for the state's portion of costs for expanded Medicaid coverage through a tax on healthcare insurance and the revenue of certain hospitals.

The Affordable Care Act, also known as Obamacare, was enacted in March 2010. Between 2013 and 2016, no statewide ballots featured measures related to Obamacare. In 2017, voters in Maine approved a ballot measure to expand Medicaid to persons under the age of 65 and with incomes equal to or below 138 percent of the federal poverty line. The measure was the first citizen initiative to implement an optional provision of Obamacare.

2018 measures:

Measure	Description	Status
Idaho Proposition 2	Expand coverage to 138 percent of the federal poverty line
Montana I-185	Extend expanded coverage and increase tobacco taxes	d
Nebraska Initiative 427	Expand coverage to 138 percent of the federal poverty line	a
Utah Proposition 3	Expand to 138 percent of the federal poverty line and increase sales tax
Oregon Measure 101	Upheld health insurance tax to fund expanded coverage	a

Text of measure

Short ballot title

The short ballot title was as follows:

“

An initiative to provide that the state shall amend its state plan to expand Medicaid eligibility to certain persons.

”

Long ballot title

The long ballot title was as follows:

“

Relating to Medicaid; amending chapter 2, title 56, Idaho Code, by the addition of a new section 56-267, Idaho Code, to provide that the state shall amend its state plan to expand Medicaid eligibility to certain persons and to provide that the department of health and welfare is required and authorized to take all actions necessary to implement the provisions of this section; and amending section 56-262, Idaho Code, to provide a correct code reference.

”

Full text

The full text of the measure can be viewed here (Page 10).

Readability score

See also: Ballot measure readability scores, 2018

Using the Flesch-Kincaid Grade Level (FKGL and Flesch Reading Ease (FRE) formulas, Ballotpedia scored the readability of the ballot title and summary for this measure. Readability scores are designed to indicate the reading difficulty of text. The Flesch-Kincaid formulas account for the number of words, syllables, and sentences in a text; they do not account for the difficulty of the ideas in the text. The attorney general wrote the ballot language for this measure. The FKGL for the ballot title is grade level 13, and the FRE is 36. The word count for the ballot title is 19, and the estimated reading time is 5 seconds. The FKGL for the ballot summary is grade level 33, and the FRE is -13. The word count for the ballot summary is 71, and the estimated reading time is 18 seconds. In 2018, for the 167 statewide measures on the ballot, the average ballot title or question was written at a level appropriate for those with between 19 and 20 years of U.S. formal education (graduate school-level of education), according to the FKGL formula. Read Ballotpedia's entire 2018 ballot language readability report here.

Support

Idahoans for Healthcare led the campaign in support of this initiative.

Supporters

Officials

• Gov. Butch Otter (R)
• Paulette Jordan (D), 2018 gubernatorial candidate
• Christy Perry (R-11B)

Former officials

• Boise School District Board Member A.J. Balukoff (D)

Organizations

• Our Revolution
• Reclaim Idaho
• Idaho Medical Association
• Idaho chapter of the American Heart Association
• American Lung Association
• The Idaho Sheriffs Association
• Idaho Education Association
• Idaho School Boards Association

Businesses

• Chobani
• Clif Bar

Arguments

• Christy Perry (R-11B), co-chair of Reclaim Idaho, said, “I am super excited about having the public be able to weigh in on it. I think it’s a great bipartisan effort. Like a lot of legislators, I’ve had my frustrations with being unable to move that ball forward in the legislative arena. So I had been watching this kind of grass-roots effort going on across the state with some great interest."

• The Idaho Education Association and the Idaho School Boards Association wrote, "Student achievement is the primary goal of our associations’ advocacy for the public education system, and studies show that a population with robust access to health care has increased chances for success. Having a parent or guardian whose health is poor has a direct impact on a student’s opportunities. Decreased academic performance, spotty or intermittent attendance, increased dropout rates, and more serious behavioral problems have an overall negative, long-lasting effect on a student’s cognitive skills and attitudes. Healthy families are essential to a student’s academic success."

• Medicaid for Idaho leader, Tracy Olson, said, "It is fiscally irresponsible to refuse to keep federal dollars here in Idaho that would be used to help Idahoans. We pay federal taxes. We should benefit from them like other states that have expanded Medicaid."

• Chris Goetz, Clearwater County sheriff and government affairs chair for the sheriff's association, said, "Sheriffs voted overwhelmingly to support Proposition 2 to save taxpayers money, to keep people out of the jails, and to keep people out of the emergency room. By expanding coverage to low-income people with health issues or mental health issues, they’re more likely to contribute to society and less likely to end up back in the system."

• David Schlactus, CEO of Valley Medical Center in Lewiston, Idaho said, "The more of our community that has a primary care physician, the better. The better we can help control chronic conditions and help improve the health of our community, the better we can help lower costs.” Idahoans who fall into the "gap" of making too much money to qualify for Medicaid but still cannot afford health insurance are the primary clients of the Valley Medical Center, which operates on a sliding-scale and is funded through donations, grants, and state funds. Arguments in support of the measure say that if the state expanded Medicaid, reliance on free clinics would decrease.

• Emily Strizich of Reclaim Idaho said, “This initiative would bring health care coverage to those who need it the most, and it will allow Idahoans to decide what we want in our health care system, no matter what politicians in Boise or Washington, D.C. do. These are moms and dads who work hard in jobs that don’t provide health coverage, and people who are nearing retirement who have lost their jobs. Many have been forced to put off needed care and haven’t been able to see a doctor in years.”

• Lauren Necochea of Idaho Voices for Children said, “The system we have today just doesn’t make sense. And I haven’t heard anyone defend the status quo, where one family can get a tax credit to purchase health coverage, and the family next door, who might make a little less, or have another child, doesn’t get any help to cover health care costs."

Opposition

The Work, Not Obamacare PAC led the campaign in opposition to Proposition 2.

Opponents

Idaho Freedom Foundation Rep. John VanderWoude, R-Nampa Rep. Heather Scott, R-Blanchard Rep. Sage Dixon, R-Ponderay Rep. Vito Barbieri, R-Dalton Gardens Rep. Ron Mendive, R-Coeur d’Alene Rep. Priscilla Giddings, R-White Bird Rep. Paul Shepherd, R-Riggins Rep. Dorothy Moon, R-Stanley Rep. Judy Boyle, R-Midvale Rep. Brent Crane, R-Nampa Rep. Joe Palmer, R-Meridian Rep. James Holtzclaw, R-Meridian Rep. Tom Dayley, R-Boise Rep. Christy Zito, R-Hammett Rep. Barbara Ehardt, R-Idaho Falls Rep. Greg Chaney, R-Caldwell Rep. Steven Harris, R-Meridian Rep. Gayann DeMordaunt, R-Eagle Rep. Ron Nate, R-Rexburg Rep. Karey Hanks, R-St. Anthony Rep. Bryan Zollinger, R-Idaho Falls

Arguments

• Fred Birnbaum, vice president of the Idaho Freedom Foundation argued, "Currently, without expansion, any single adult who works full time is eligible for highly-subsidized coverage on the exchange with Advanced Premium Tax Credits. Even most part-time workers are eligible, so long as you earn at least $12,140 per year. Expansion is primarily an entitlement for the adult able-bodied, nonworking poor. The initiative to expand Medicaid builds upon the failed ACA and is destined to be a cure worse than the disease. There are alternatives to expanding government-run health care that protect the doctor-patient relationship, don't require everyone to be on the same mandated plan and won't bankrupt taxpayers."

• Dr. John Livingston, a retired Idaho surgeon, wrote, "I have two main concerns with expanding Medicaid. My first and biggest concern: Medicaid expansion will allow many people to believe that when government steps in, they are discharged of their personal obligation to take care of their own family, friends, and neighbors. My second concern is, because of changing demographics—smaller, more mobile families, and the loss of community that results from a reliance on government programs—the final cost for government medical care will make it impossible to support the other services that are truly the province of government."

• United States Representative, Raul Labrador of Idaho, who ran unsuccessfully for governor of Idaho in 2018, said that if he was elected, he would have considered overturning the Medicaid initiative if it passed.

• Republican delegates at the Idaho GOP Convention in Pocatello adopted a non-binding resolution, sponsored by the Republican nominee for lieutenant governor of Idaho, Janice McGeachin, to formally oppose the Medicaid expansion initiative. The resolution said, "...the current Medicaid program is already cannibalizing dollars for schools and roads by growing at a faster rate than other major programs and expansion will further erode support for other critical spending needs.” Another resolution suggested encouraging private nonprofits to provide healthcare to those in the coverage gap rather than expanding Medicaid.

Media editorials

Support

• The Post Register wrote, "Much of the case against Proposition 2, which would expand Medicaid to cover 62,000 working poor, has been dominated by distractions. [...] Medicaid expansion isn’t a slippery slope or the thin edge of the wedge. It’s not a dark plot being pushed on the Gem State by outsiders. It’s a sensible policy that every Idahoan who cares about their neighbors’ well-being ought to support."

• The Moscow-Pullman Daily News wrote, "The state Legislature has failed to address a situation that has resulted in more than 60,000 Idahoans falling into the so-called "Medicaid gap." These residents are ineligible for Medicaid and too poor to qualify for subsidies and credits under the Affordable Care Act. So, these people, our friends and neighbors, either go without care or are forced to rely on county indigent care programs, which, not surprisingly, are severely costly and troublesome for local governments. Prop 2 would extend Medicaid coverage to these residents. Economics aside, we believe everyone in our society should have access to quality health care. Voters don't always get things right, but if they pass Prop 2, this won't be one of those cases."

Opposition

• The Wall Street Journal: "Nebraska and Idaho’s ballot measures leave the funding details for another day, ostensibly because voters might figure out that expansion is more expensive than it appears. [...] Medicaid expansion is a bad fiscal and health-care bargain that looks worse as time passes. States like Kentucky are already looking for reforms like work requirements before the “free” money drowns their state fisc. Voters would be wise to reject the phony compassion and focus scarce resources on the poor and disabled."

Campaign finance

See also: Campaign finance requirements for Idaho ballot measures

Two committees registered to support Proposition 2: Idahoans for Healthcare and Reclaim Idaho. Together, the committees had raised $1.78 million and had spent $1.77 million. The largest donors were The Fairness Project, St Luke's Health System, and Saint Alphonsus Regional Medical Center.

The Work, Not Obamacare PAC was formed as a miscellaneous committee. Fred Birnbaum—vice president of Idaho Freedom Foundation, an organization with which the treasurer of Work, Not Obamacare PAC was associated—said that the PAC would be working to oppose Proposition 2. The committee had raised $59,930 and had spent $65,713. The largest donors were Daniel Brockett, Doyle Beck, and Regan Properties LLC.

	Cash Contributions	In-Kind Contributions	Total Contributions	Cash Expenditures	Total Expenditures
Support	$1,728,128.13	$54,545.46	$1,782,673.59	$1,715,031.29	$1,769,576.75
Oppose	$53,016.00	$6,914.92	$59,930.92	$29,429.47	$36,344.39
Total	$1,781,144.13	$61,460.38	$1,842,604.51	$1,744,460.76	$1,805,921.14

Support

The following table includes contribution and expenditure totals for the committees in support of the measure.

Committees in support of Proposition 2
Committee	Cash Contributions	In-Kind Contributions	Total Contributions	Cash Expenditures	Total Expenditures
Idahoans for Healthcare	$1,615,293.70	$50,549.99	$1,665,843.69	$1,604,659.81	$1,655,209.80
Reclaim Idaho	$112,834.43	$3,995.47	$116,829.90	$110,371.48	$114,366.95
Total	$1,728,128.13	$54,545.46	$1,782,673.59	$1,715,031.29	$1,769,576.75

Top donors

The top five donors in support of this initiative are listed below:

Donor	Cash	In-kind	Total
The Fairness Project	$400,000.00	$30,522.21	$430,522.21
Saint Alphonsus Regional Medical Center	$250,000.00	$0.00	$250,000.00
St Luke's Health System	$250,000.00	$0.00	$250,000.00
Idaho Hospital Association	$200,000.00	$0.00	$200,000.00
Susie and A.J. Balukoff	$100,000.00	$0.00	$100,000.00
Idaho Medical Association	$48,769.97	$0.00	$48,769.97

Opposition

The following table includes contribution and expenditure totals for the committees in opposition to the initiative.

Committees in opposition to Proposition 2
Committee	Cash Contributions	In-Kind Contributions	Total Contributions	Cash Expenditures	Total Expenditures
Work, Not Obamacare PAC	$53,016.00	$6,914.92	$59,930.92	$29,429.47	$36,344.39
Total	$53,016.00	$6,914.92	$59,930.92	$29,429.47	$36,344.39

Top donors

The top five donors in support of this initiative are listed below:

Donor	Cash	In-kind	Total
Daniel Brockett	$15,000.00	$0.00	$15,000.00
Doyle Beck	$10,000.0	$0.00	$10,000.00
Regan Properties LLC	$10,000.00	$0.00	$10,000.00
Idaho Freedom Foundation	$0.00	$3,136.47	$3,136.47
Jon Christianson	$5,000.00	$0.00	$5,000.00

Methodology

To read Ballotpedia's methodology for covering ballot measure campaign finance information, click here.

Reports and analyses

Note: The inclusion of a report, white page, or study concerning a ballot measure in this article does not indicate that Ballotpedia agrees with the conclusions of that study or that Ballotpedia necessarily considers the study to have a sound methodology, accurate conclusions, or a neutral basis. To read a full explanation of Ballotpedia's policy on the inclusion of reports and analyses, please click here.

In July 2018, Milliman, Inc. released a report titled "Financial Impacts from Medicaid Expansion in Idaho" commissioned by the Idaho Department of Health and Welfare.

The executive summary can be expanded here

“ At the request of the Idaho Department of Health and Welfare (DHW), we prepared this report to analyze the cost impact of expanding Medicaid coverage under the Patient Protection and Affordable Care Act (ACA) as a possible result of a voter-initiated ballot measure. The ballot measure proposes expanding Medicaid coverage to the population of adults with income up to 133% of the Federal Poverty Level (FPL), with the standard Medicaid income rules allowing those with up to 138% of FPL to enroll. Throughout this report, we refer to state and local offsets. The nature of this forecast is based upon the data and information available at this time. Actual enrollment levels and costs will vary from these estimates as the actual results are observed relative to the assumptions contained within this report. Actual results could be higher or lower than our estimates. This can be due to changes in the number of persons eligible, enrollment take-up rates, per member costs, cost offsets, or federal funding. State funds will be needed to pay the state share of a potential Medicaid expansion. We have assumed a 90% federal medical assistance percentage (FMAP) for the duration of the projection period. The total ten year cost estimate from SFY2020 to SFY2030 in state and local funds is $105.1 million net of projected offsets for currently authorized programs. The total state and federal ten year net cost (reflecting savings from existing state and local funds) is $4,796.3 million. ”

The full report can be read here.

Background

Medicaid expansion under the ACA

See also: Medicaid and Obamacare

The Affordable Care Act (ACA), also known as Obamacare, was signed into law on March 23, 2010. The ACA provided for the expansion of Medicaid to cover all individuals earning incomes up to 138 percent of the federal poverty level, which amounted to $16,394 for individuals and $33,534 for a family of four in 2016. The law was designed to provide 100 percent of funding to cover the new recipients for the first three years and to cut off federal Medicaid funding to states that chose not to expand coverage. However, the United States Supreme Court ruled in National Federation of Independent Business v. Sebelius (2012) that the federal government could not withhold Medicaid funds from states that chose not to expand eligibility. According to the Kaiser Family Foundation, this ruling had the practical effect of making Medicaid expansion optional for states. By January 1, 2017, 19 states, including Utah, had chosen not to expand eligibility.

From 2014 to 2016, the federal government covered 100 percent of the costs of state expansion of Medicaid. In 2017, the total cost that the federal government financed decreased to 95 percent. The ACA was designed to decrease the amount the federal government covers to 94 percent in 2018, 93 percent in 2019, and 90 percent in 2020 and subsequent years.

The Affordable Care Act had not provided tax credits to adults with household incomes less than the federal poverty line because the law had aimed to cover these people under Medicaid. In states that did not expand Medicaid, many of these adults fell into a coverage gap in which they neither qualified for Medicaid nor for federal tax credits to purchase health insurance. As of 2016, around 2.6 million people fell into this coverage gap across the 19 states that did not expand Medicaid.

Adoption of Medicaid expansion under the ACA

As of January 2022, a total of 38 states and Washington, D.C., had expanded or voted to expand Medicaid, while 12 states had not. The map below provides information on Medicaid expansions by state; for states that expanded, hover over the state to view the political affiliation of the governor at the time of expansion.

Medicaid expansion on the ballot

Congress approved the Affordable Care Act, also known as Obamacare, on March 21, 2010, and President Barack Obama signed the legislation into law on March 23, 2010. Almost 20 weeks after the law's passage, voters in Missouri approved a ballot measure to oppose the individual mandate and employer mandate. The measure was the first to oppose Obamacare. Following the August 2010 vote in Missouri, voters in eight other states cast ballots on measures designed to oppose provisions of Obamacare. The American Legislative Exchange Council (ALEC), which developed model legislation that some of the ballot measures utilized, contended that the measures provided states with a legal framework to challenge Obamacare. Opponents argued that the measures were symbolic, having no effect on the federal healthcare law.

Between 2013 and 2016, no statewide ballots featured measures related to Obamacare. In 2017, voters in Maine considered a ballot measure to expanded Medicaid to persons under the age of 65 and with incomes equal to or below 138 percent of the federal poverty line. The measure, which was approved, was the first to implement a provision of Obamacare that, due to a court ruling, state governments were allowed to choose whether or not to enact. At the time, 19 states, including Maine, had chosen not to expand Medicaid. Inspired by the win in Maine, campaigns began in additional states to expand Medicaid through citizen-initiated ballot measures.

Less than 80 days after the vote in Maine, another type of conflict related to Medicaid expansion was on the ballot in Oregon. Oregon Measure 101 was a veto referendum against assessments and taxes to provide funding for Medicaid expansion. The expansion was fully funded by the federal government from 2014 through 2016. In 2017, the federal government provided 95 percent of funding for Medicaid expansion, and the remainder was the responsibility of the state government. Federal funding for Medicaid expansion was scheduled to decrease to 94 percent in 2018, 93 percent in 2019, and 90 percent in 2020 and after. Oregon was the first state with a ballot measure, which voters approved, addressing how to fund Medicaid expansion.

Following is a list of statewide ballot measures related to Medicaid expansion:

• The Montana Medicaid Expansion Initiative was proposed for the November 4, 2014 ballot in Montana as an initiated state statute. Proponents failed to collect enough signatures, and therefore it did not qualify for the ballot.
• The Ohio Medicaid Expansion Initiative was proposed for the November 4, 2014 ballot in Ohio as an indirect initiated state statute. Proponents failed to collect enough signatures, and therefore it did not qualify for the ballot.
• The Maine Medicaid Expansion Initiative, Question 2, was on the ballot in Maine as an indirect initiated state statute on November 7, 2017. It was approved. Gov. Paul LePage (R) opposes expanding Medicaid in Maine and has refused to implement the law. On April 3, 2018, the state missed the deadline to file an application for Medicaid expansion with the federal government in order to secure funding by July 2018, as required by Question 2.
• The Missouri Medicaid Expansion Initiative was proposed for the November 6, 2018 ballot in Missouri as an initiated state statute. Proponents did not submit signatures for the initiative, therefore the measure was not on the ballot.
• Oregon Measure 101 was on the ballot in January 2018. It was a veto referendum targeting the repeal of legislation designed to healp fund Medicaid expansion costs through a tax/assessment on heathcare insurance premiums. Voters supported the bill by approving Measure 101.
• Idaho Proposition 2 qualified for the ballot as a citizen initiative and was designed to expand Medicaid eligibility to those under sixty-five years old, whose income is 133 percent of the federal poverty level or below and who are not eligible for other state insurance coverage.
• The Nebraska Medicaid Expansion Initiative was on the ballot in Nebraska as an initiated state statute on November 6, 2018. A total of 84,098 valid signatures were required for the measure to qualify for the ballot.
• Utah Proposition 3, the Medicaid Expansion Initiative, was on the ballot in Utah as an initiated state statute on November 6, 2018. Proponents of the measure submitted 147,280 valid signatures and met signature thresholds in 26 of 29 state Senate districts.
• Montana I-185, Extend Medicaid Expansion and Increase Tobacco Taxes Initiative (2018)

Idaho Catastrophic Health Care Program

As of May 2018, Idaho has a program to help those who cannot afford healthcare, referred to as the CAT fund. Below is a description of the program:

“

The Catastrophic Health Care Program was established to meet the needs of the medically indigent in Idaho who do not qualify for state or federal health and welfare programs, but do qualify for county assistance. Beginning July 1, 2009, the resident county is responsible for the first $11,000 in medical bills for the medically indigent in any twelve month period. The state program is responsible for all medical bills in excess of $11,000. Appropriations from the General Fund to this program are transferred into the Catastrophic Health Care Fund which is perpetually appropriated for expenses incurred.

”

In 2016, the resident county payments and Catastrophic Health Care Fund payments program cost the state $33.9 million. In Idaho, counties levy property taxes to fund the programs that cover unpaid medical bills. According to the Idaho Statesman, "Idaho counties assess property tax levies specifically for unpaid medical bills. Ada County's indigent services levy [in 2018] costs property owners $19.77 per $100,000 of assessed value. Canyon County's levy charges more than four times that — the most in the state." Proponents of Medicaid expansion argue that Medicaid expansion would save the state money by reducing reliance on the Catastrophic Health Fund programs. Roger Christiansen, chairman of the CAT fund's board said, "If it is implemented, it will have an impact."

Path to the ballot

See also: Laws governing the initiative process in Idaho

The state process

In Idaho, the number of signatures required to qualify an initiated state statute for the ballot is equal to 6 percent of the registered voters as of the state's last general election. Petitions can be circulated for up to 18 months. Idaho features a distribution requirement that signatures equal to at least 6 percent of registered voters in 18 of the state's 35 legislative districts be included in petitions. Signatures for initiatives must be submitted by May 1 of the year in which the measure is to go on the ballot.

The requirements to get an initiated state statute certified for the 2018 ballot:

• Signatures: 56,192 valid signatures were required.
• Deadline: The deadline to submit signatures was May 1, 2018.

Initiative petition signatures are verified by county clerks and then sent to the secretary of state for certification.

Cost of signature collection:
Ballotpedia found no petition companies that received payment from the sponsors of this measure, which means signatures were likely gathered largely by volunteers. A total of $0.00 was spent to collect the 56,192 valid signatures required to put this measure before voters, resulting in a total cost per required signature (CPRS) of $0.00.

Details about this initiative

The group leading the ballot initiative effort, Reclaim Idaho, submitted the measure to the secretary of state’s office during the week of Oct. 16.

The secretary of state reviews proposals for compliance with technical requirements and then sends the proposed initiative to the state attorney general for further review. The attorney general is required to evaluate proposals and provide recommendations on substance, form, and style. These revisions are advisory; petitioners are free to accept or reject them. After the review, the sponsor must re-submit revised proposals to the secretary of state. The attorney general then assigns the measure a short and long ballot title.

Supporters are given 18 months to gather signatures once an initiative has received a ballot title. They are not allowed to collect signatures past April 30th of the year in which the respective initiative would appear on the ballot. In 2018, petitioners must submit a minimum of 56,192 valid signatures in order for an initiated state statute to qualify for the ballot.

On November 10, 2017, Deputy Attorney General Scott Keim said the initiative contains an emergency clause requiring the state to implement Medicaid expansion immediately if the proposal is approved. Keim said this could be problematic because emergency clauses normally apply to legislation but not ballot initiatives.

On February 2, 2018, proponents of the initiative announced that more than 10,000 signatures from registered voters had been collected. On March 20, 2018, proponents gave an update that they had collected about 29,000 signatures.

As of April 30, 2018, proponents of the initiative said the group has collected over 60,000 signatures statewide. The requirement to get on the ballot is 56,192.

On July 17, 2018, Idaho Secretary of State Lawerence Denney announced that the measure had qualified for the ballot. Proponents submitted 75,134 verified signatures. The requirement to get on the ballot was 56,192 valid signatures. Proponents also needed to gather signatures equal to at least 6 percent of registered voters in at least 18 of Idaho's 35 legislative districts. The measure met signature thresholds in 21 of 35 legislative districts.

How to cast a vote

See also: Voting in Idaho

Poll times

In Idaho, all polls are open from 8:00 a.m. to 8:00 p.m. local time. In some instances, polls may open at 7:00 a.m., at the discretion of the local clerk. Idaho is split between Mountain and Pacific time zones. An individual who is in line at the time polls close must be allowed to vote.

Registration requirements

Check your voter registration status here.

To register to vote in Idaho, one must be a citizen of the United States, a resident of the Idaho county in which he or she is registering for at least 30 days before the election, and at least 18 years old on or before Election Day.

Registration in advance of election day may be completed online, in person at the county clerk's office, or by mail. The deadline to register to vote online is the 24th day before the election A registration application submitted by mail must be postmarked by the 25th day before the election. Voters may also register in-person at an early voting location or on Election Day.

Idaho requires a photo ID and proof of residence to register to vote in person. According to the secretary of state's website, a valid photo ID is one of:

• Idaho Driver’s License
• Idaho Identification Card
• Passport or Federal ID
• Tribal ID Card
• Concealed Weapons License issued by a county sheriff in Idaho

A valid proof of residence is one of:

• Above photo ID with the correct address
• Proof of insurance
• Mortgage, lease, or rental agreement
• Property tax assessment, bill
• Utility bill (no cell bills)
• Bank/credit card statement
• Paystub/paycheck
• Intake document to a care facility
• Enrollment letter from an Idaho high school or university
• Letter from a social service agency

A voter registering to vote by a mail application must provide their Idaho driver's license number or their social security number. If the voter is registering for the first time they must also include a copy of a photo ID and proof of residence. Eligible documents are listed above.

Automatic registration

Idaho does not practice automatic voter registration.

Online registration

See also: Online voter registration

Idaho has implemented an online voter registration system. Residents can register to vote by visiting this website.

Same-day registration

Idaho allows same-day voter registration.

Residency requirements

Idaho law requires 30 days of residency in one of the state’s counties before a person may vote.

Verification of citizenship

See also: Laws permitting noncitizens to vote in the United States

Idaho does not require proof of citizenship for voter registration. An individual applying to register to vote must attest that they are a U.S. citizen under penalty of perjury.

All 49 states with voter registration systems require applicants to declare that they are U.S. citizens in order to register to vote in state and federal elections, under penalty of perjury or other punishment. As of January 2025, six states — Alabama, Arizona, Georgia, Kansas, Louisiana, and New Hampshire — had passed laws requiring verification of citizenship at the time of voter registration. However, only two of those states' laws were in effect, in Arizona and New Hampshire. In three states — California, Maryland, and Vermont — at least one local jurisdiction allowed noncitizens to vote in some local elections as of November 2024. Noncitizens registering to vote in those elections must complete a voter registration application provided by the local jurisdiction and are not eligible to register as state or federal voters.

Verifying your registration

The page Search for My Voter Record, run by the Idaho Secretary of State's office, allows residents to check their voter registration status online.

Related measures

• Oregon Measure 101, Healthcare Insurance Premiums Tax for Medicaid Referendum (January 2018)
• Missouri Medicaid Expansion Initiative (2018)
• Utah Proposition 3, Medicaid Expansion Initiative (2018)
• Maine Question 2, Medicaid Expansion Initiative (2017)

State profile

Demographic data for Idaho
	Idaho	U.S.
Total population:	1,652,828	316,515,021
Land area (sq mi):	82,643	3,531,905
Race and ethnicity**
White:	91.7%	73.6%
Black/African American:	0.6%	12.6%
Asian:	1.3%	5.1%
Native American:	1.3%	0.8%
Pacific Islander:	0.1%	0.2%
Two or more:	2.6%	3%
Hispanic/Latino:	11.8%	17.1%
Education
High school graduation rate:	89.5%	86.7%
College graduation rate:	25.9%	29.8%
Income
Median household income:	$47,583	$53,889
Persons below poverty level:	16.9%	11.3%
Source: U.S. Census Bureau, "American Community Survey" (5-year estimates 2010-2015) Click here for more information on the 2020 census and here for more on its impact on the redistricting process in Idaho. **Note: Percentages for race and ethnicity may add up to more than 100 percent because respondents may report more than one race and the Hispanic/Latino ethnicity may be selected in conjunction with any race. Read more about race and ethnicity in the census here.

Presidential voting pattern

See also: Presidential voting trends in Idaho

Idaho voted Republican in all seven presidential elections between 2000 and 2024.

More Idaho coverage on Ballotpedia

• Elections in Idaho
• United States congressional delegations from Idaho
• Public policy in Idaho
• Endorsers in Idaho
• Idaho fact checks
• More...

External links

• Idaho 2018 Voters' Guide

Support

• Idahoans for Healthcare website
• Idahoans for Healthcare Facebook
• Idahoans for Healthcare Twitter

Opposition

Email links to editor@ballotpedia.org.

See also

2018 measures

• 2018 ballot measures
• Healthcare on the ballot

Idaho

• Idaho ballot measures
• Idaho ballot measure laws

News and analysis

• Ballot measure lawsuits
• Ballot measure readability
• Ballot measure polls