Nonprofit scores with progressive health ballot measures in red states

A progressive nonprofit cemented its status as a key driver of state health policies in the midterms, winning popular votes on ballot questions dealing with abortion rights, Medicaid expansion and medical debt.

Driving the news: The Fairness Project scored multiple wins Tuesday night, including in South Dakota and Arizona, whose conservative-led legislatures have resisted taking up those causes.

• South Dakota became the seventh red state since 2017 to pass a Medicaid expansion question that the group got on the ballot.
• The group also succeeded with a medical debt relief ballot question in Arizona that could become a model for other states dealing with high health costs and aggressive collection tactics.
• And it won passage of abortion rights measures in Michigan and Vermont that made it much harder for lawmakers there to enact bans.

Why it matters: The South Dakota Medicaid win, in particular, defied the notion that red state voters aren't receptive to expanding safety net program their Republican legislators have shunned.

• It also put pressure on 11 holdout states that haven't expanded their Medicaid programs, said Eliot Fishman, senior director of health policy at Families USA.

What they're saying: Kelly Hall, the Fairness Project’s executive director, told Axios the nonprofit went on offensive during the Trump years, by targeting states while federal lawmakers were locked in a bitter battle over repealing the Affordable Care Act.

• The group has seized on ballot measures, a “powerful but difficult to use tool” Hall said is seen as a last resort because of the difficulties drafting language and getting the measures certified.
• It lines up financial assistance for local advocacy groups who make the case to voters.
• South Dakota's Medicaid measure was fueled by a multi-million dollar campaign that drew the state's biggest hospitals, interfaith leaders, farmers unions and businesses.

The other side: Republicans like South Dakota Gov. Kristi Noem have long had reservations about progressive policies that expand coverage, citing the potential cost to the state.

• FamiliesUSA’s Fishman says “it’s not a compelling argument” since the federal government picks up 90% of the tab in Medicaid expansion.

Zoom in: Some Republicans have embraced Medicaid expansion as a way to control future health spending.

• In 2018, Hall said some people in Idaho who collected signatures to put a Medicaid question on the ballot wore MAGA hats and called themselves “Trump voters for Medicaid.”

• In South Dakota, Republican Rep. Greg Jamison cut an ad for the campaign saying he’d be voting for Medicaid expansion to limit the future economic impact on the state.
• Skepticism "has been much more diminished in 2020 and 2022 cycles because people can really see the power of what’s possible," Hall said.

But, but, but: Only two of the 11 remaining Medicaid holdout states that haven’t — Wyoming and Florida — have the option to vote for expansion via ballot measures. The others would leave such questions to their legislatures.

• Florida requires a 60% supermajority to pass, which complicates prospects, FamiliesUSA’s Fishman tells Axios. South Dakota voters overwhelmingly rejected an attempt to changes the state's threshold from a simple majority this June.

What’s next: Hall said it’s too soon to discuss the next battlegrounds but said the group is poised to keep pushing for health policy, like abortion rights, in states where Republicans have resisted it.

• "Because those legislators are refusing to govern on the issues that matter most to voters including health care ... voters are having to take matters into their own hands," she said.