Why there won't be a wave of Medicaid ballot initiatives

Democrats were over the moon Tuesday when Maine became the first state to adopt the Affordable Care Act's Medicaid program through a ballot initiative. Buoyed by that success, advocates are already looking ahead to similar ballot measures in other states.

• There are 18 states that haven't expanded Medicaid.
• Supporters are already collecting signatures to get Medicaid referendums on the ballot next year in Idaho and Utah.
• Advocates said Nebraska and Missouri are also potential candidates for Maine-style ballot questions, but serious efforts aren't under way yet in those states.

Reality check: There are limits to how far that strategy can take them. Some of the biggest and most politically important states on that list — the ones that would be the biggest coups for expansion supporters — are bad candidates for referendums like Maine's, according to Jonathan Schleifer, executive director of the Fairness Project, which works on progressive ballot initiatives.

• Expanding Medicaid in Texas and Florida, for example, would add millions of people to the ACA's coverage rolls — advancing the law's core mission and helping to secure it politically.
• But both make referendums difficult, Schleifer said. Texas' legislature has a lot of power to undo successful initiatives, and Florida requires 60% support for a measure to pass. And the Fairness Project tries to focus on fights it can win.

The bottom line: The pro-expansion effort will largely remain a grind through state legislatures. On that front, advocates have their eyes on Kansas, North Carolina and Virginia. They're also hoping Georgia and Tennessee could come into play down the road.

• Ballot initiatives are expensive, resource-intensive and politically risky, said Katherine Howitt, associate policy director at the advocacy group Community Catalyst. (Good luck getting a state legislature to pass a policy if it fails as a referendum.)
• So, as exciting as Maine was for liberals, it might be most helpful as an argument to state legislators that expansion is popular.
• "If there's a path to doing it legislatively, that might be preferable," Howitt said.