An Overview of State Approaches to Adopting the Medicaid Expansion

Issue Brief
  1. U.S. Department of Health and Human Services, Office of The Assistant Secretary for Planning and Evaluation, 2019 Poverty Guidelines. https://aspe.hhs.gov/poverty-guidelines

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  2. Kaiser Family Foundation, Status of State Medicaid Expansion Decisions: Interactive Map (Washington, DC: Kaiser Family Foundation, accessed February 8, 2019), https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/.

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  3. Robin Rudowitz and Andy Schneider, The Nuts and Bolts of Making Medicaid Policy Changes: An Overview and Look at the Deficit Reduction Act (Washington, DC: Kaiser Family Foundation, July 2006), https://www.kff.org/medicaid/issue-brief/the-nuts-and-bolts-of-making-medicaid/.

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  4. The eight states using Section 1115 waiver authority to implement expansion programs in ways not otherwise permitted under federal law are Arkansas, Arizona, Indiana, Iowa, Michigan, Montana, New Hampshire, and New Mexico.

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  5. Kaiser Family Foundation State Health Facts, Status of State Action on the Medicaid Expansion Decision (Washington, DC: Kaiser Family Foundation, February 2019), https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

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  6. Ballotpedia, “Legislative Alteration,” (Ballotpedia, accessed February 12, 2019), https://ballotpedia.org/Legislative_alteration#No_restrictions

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  7. Only two states (California and Arizona) have voter approval requirements for changes to or the repeal of citizen-initiated state statutes. Both of these states have previously expanded Medicaid. For more information, see:

    Ballotpedia, “Legislative Alteration,” (Ballotpedia, accessed February 12, 2019), https://ballotpedia.org/Legislative_alteration#No_restrictions

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  8. National Health Law Center and National Association of Community Health Centers, Role of State Law in Limiting Medicaid Changes. February 2008. http://www.nachc.org/client/NHELP-NACHC-St-by-St-Chart-Final.pdf

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  9. H.F. 9, 88th Minnesota Legislature (enacted 2013.) https://www.revisor.mn.gov/bills/bill.php?b=house&f=HF9&ssn=0&y=2013.

    Governor Mark Dayton, State expands health coverage for 35,000 Minnesotans. (Press Release, Governor of Minnesota,) February 19, 2013. http://mn.gov/governor/newsroom/pressreleasedetail.jsp?id=102-55000.

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  10. H.B. 0228, Maryland General Assembly 2013 Regular Session (enacted 2013.) http://mgaleg.maryland.gov/webmga/frmMain.aspx?pid=billpage&stab=01&id=hb0228&tab=subject3&ys=2013RS.

    The House Fiscal and Policy Note for this bill indicates that there is “no legal requirement that Maryland enact legislation to participate in the Medicaid expansion…however, all previous expansions of the Maryland Medicaid program have been done through legislation.”

    Department of Legislative Services, Fiscal and Policy Note Revised: Maryland Health Progress Act of 2013 (House Bill 228.) (Maryland General Assembly,) 2013. http://mgaleg.maryland.gov/2013RS/fnotes/bil_0008/hb0228.pdf.

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  11. A. 03006, New York State Assembly – 2013 Legislative Session (enacted 2013). http://assembly.state.ny.us/leg/?bn=S02606&term=2013.

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  12. H.B. 2, New Mexico Legislature - 2013 Legislative Session (enacted 2013). http://www.nmlegis.gov/lcs/legislation.aspx?chamber=H&legtype=B&legno=%20%20%202&year=13.

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  13. H.B. 2010, Fifty-first Legislature – Special Session (enacted 2013.) http://www.azleg.gov/DocumentsForBill.asp?Bill_Number=HB2010&Session_ID=111.

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  14. Robin Rudowitz, Samantha Artiga and MaryBeth Musumeci. The ACA and Medicaid Expansion Waivers. Kaiser Family Foundation, updated February 2015. https://www.kff.org/medicaid/issue-brief/the-aca-and-recent-section-1115-medicaid-demonstration-waivers/.

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  15. Senate File 446, Iowa Legislature (enacted 2013). https://www.legis.iowa.gov/docs/publications/LGE/85/SF446.pdf

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  16. H.B. 4714, Public Act 107, Michigan Legislature (enacted 2013). https://www.legislature.mi.gov/documents/2013-2014/publicact/pdf/2013-PA-0107.pdf

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  17. S.B. 405, Sixty-fourth Legislature, Montana (enacted 2015). https://leg.mt.gov/bills/2015/sb0499/SB0405_x.pdf

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  18. Robin Rudowitz, MaryBeth Musumeci, and Alexandra Gates, Medicaid Expansion Waivers: What Will We Learn? (Washington, DC: Kaiser Program on Medicaid and the Uninsured, March 2016), https://www.kff.org/medicaid/issue-brief/medicaid-expansion-waivers-what-will-we-learn/

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  19. New Hampshire Revised Statutes, Title X Chapter 126-A:5, http://www.gencourt.state.nh.us/rsa/html/x/126-a/126-a-5.htm

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  20. Virginia General Assembly, 2018 Special Session, Virginia Acts of Assembly Chapter 2, https://budget.lis.virginia.gov/get/budget/3619/

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  21. Jennifer Lee, Virginia Department Of Medical Assistance Services 1115 Demonstration Extension Application, November 20, 2018, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/va/va-gov-access-plan-gap-pa4.pdf

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  22. Kaiser Family Foundation, Medicaid Expansion in Pennsylvania: Transition from Waiver to Traditional Coverage (Washington, DC: Kaiser Family Foundation, August 2015), https://www.kff.org/medicaid/fact-sheet/medicaid-expansion-in-pennsylvania/

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  23. Pennsylvania’s expansion program was transitioned from former-Governor Corbett’s Section 1115 expansion program to a SPA expansion program after Governor Wolf took office in 2015. For more detail, see:

    Kaiser Family Foundation, Medicaid Expansion in Pennsylvania: Transition from Waiver to Traditional Coverage (Washington, DC: Kaiser Family Foundation, August 2015), https://www.kff.org/medicaid/fact-sheet/medicaid-expansion-in-pennsylvania/

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  24. Nathaniel Herz, “Walker Says He’ll Use Executive Authority to Expand Medicaid in Alaska,” Anchorage Daily News (July 16, 2015), https://www.adn.com/politics/article/walker-says-he-ll-go-ahead-medicaid-expansion/2015/07/16/

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  25. State of Louisiana Executive Order No. JBE 16-01. http://gov.louisiana.gov/assets/docs/Issues/JBE1601.pdf

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  26. In Kentucky, the original executive order adopting the Medicaid expansion under former Governor Beshear was challenged in court as an unlawful delegation of power from the legislature to the executive branch. Eventually, the judge upheld the executive order based on existing state law that gave the Secretary of Health and Family Services authority “to take advantage of all federal funds that may be available for medical assistance…the secretary…may by regulation comply with any requirement that maybe imposed or opportunity that may be presented by federal law.”

    David Adams, et al v. Commonwealth of Kentucky et al, No. 13-CI-605 (Franklin Circuit Court – Division 1, September 3, 2013.) http://www.adea.org/uploadedFiles/ADEA/Content_Conversion_Final/policy_advocacy/Documents/emailDist/5PAGES.pdf

    Kentucky Revised Statutes (KRS) 205.520 http://www.lrc.ky.gov/Statutes/statute.aspx?id=7700.

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  27. There is ongoing separate litigation in Kentucky over the Kentucky HEALTH Section 1115 waiver, which includes approval to transition Kentucky’s expansion program from SPA to Section 1115 waiver authority. However, that litigation is unrelated to the fact that Kentucky initially adopted expansion through executive action. For more information, see:

    MaryBeth Musumeci, A Guide to the Lawsuit Challenging CMS’s Approval of the Kentucky HEALTH Medicaid Waiver, (Washington, DC: Kaiser Family Foundation, January 2018), https://www.kff.org/medicaid/issue-brief/a-guide-to-the-lawsuit-challenging-cmss-approval-of-the-kentucky-health-medicaid-waiver/

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  28. In Alaska, lawmakers opposed to the Medicaid expansion filed a lawsuit against former Governor Walker for his decision to expand through executive authority, but the Alaska Supreme Court refused to delay the September 1, 2015 implementation date. The case was then dismissed in Superior Court in March 2016, and lawmakers ultimately dropped their appeal in June 2016.

    Associated Press, “Alaska Supreme Court Refuses to Block Medicaid Expansion,” The Wall Street Journal (August 31, 2015), https://www.wsj.com/articles/alaska-supreme-court-wont-block-medicaid-expansion-1441069920

    Tegan Hanlon, “Legislative Council Drops Medicaid Lawsuit Against Gov. Walker,” Anchorage Daily News (June 29, 2016), https://www.adn.com/politics/2016/06/29/legislative-council-drops-medicaid-lawsuit-against-gov-walker/

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  29. Robert Higgs, “Controlling Board Gives OK to Use Federal Money to Pay for Medicaid Expansion in Ohio,” Cleveland.com (October 22, 2013), https://www.cleveland.com/open/index.ssf/2013/10/controlling_board_gives_ok_to.html

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  30. The Ohio Supreme Court upheld Ohio’s expansion after Republican lawmakers and anti-abortion groups filed a lawsuit against the Ohio Controlling Board for acting contrary to the legislative intent of the General Assembly.

    State ex rel. Cleveland Right to Life v. State of Ohio Controlling Bd., 138 Ohio St.3d 57, 2013-Ohio-5632. http://www.supremecourt.ohio.gov/rod/docs/pdf/0/2013/2013-Ohio-5632.pdf

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  31. S. 4, North Carolina State Legislature – 2013-2014 Session (2013.) http://www.ncleg.net/gascripts/BillLookUp/BillLookUp.pl?Session=2013&BillID=S4.

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  32. H. B. 990, Georgia General Assembly 2013-2014 Regular Session, (2014.) http://www.legis.ga.gov/Legislation/en-US/display/20132014/HB/990.

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  33. H.B. 0937, 108th Tennessee General Assembly (2014.) http://wapp.capitol.tn.gov/apps/Billinfo/default.aspx?BillNumber=HB0937&ga=108.

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  34. H.B. 2552, Kansas Legislature 2014 Regular Session, (2014.) http://www.kslegislature.org/li_2014/b2013_14/measures/hb2552/

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  35. After a long protracted debate in 2014 over the state’s budget bill around the Medicaid expansion, legislators in Virginia passed a budget bill without appropriations for the Medicaid expansion that also included an amendment, proposed by Senator Stanley, to prevent the governor from implementing the expansion on his own authority without legislative approval. Governor McAuliffe signed the budget legislation, but used his line-item veto authority to remove the Stanley amendment along with other items. However, the Speaker of the House later ruled that the line-item veto of the Stanley amendment was outside the Governor’s authority as it did not delete the entire line item but only a portion; the line item in question related to the appropriation for the state’s entire Medicaid program. After the General Assembly voted and approved other line-items vetoes, the budget became law with the Stanley amendment intact.

    Laura Snyder, Kathleen Gifford, Eileen Ellis and Jenna Walls, Putting Medicaid in the Larger Budget Context: An In-Depth Look at Four States in FY 2014 and 2015. (Kaiser Family Foundation,) October 2014. https://www.kff.org/medicaid/issue-brief/putting-medicaid-in-the-larger-budget-context-an-in-depth-look-at-four-states-in-fy-2014-and-2015/.

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  36. Specifically, the new law prohibits the Wisconsin Department of Health Services from submitting a Medicaid SPA (or making certain other Medicaid changes) to the federal government if the change has an expected fiscal effect of $7.5 million or more over the 12-month period following the implementation date without submitting the proposed SPA to the Legislature’s Joint Committee on Finance (JCF) for review. If the JCF decides to schedule a meeting to review the proposed SPA, the SPA may only be submitted to the federal government if approved by the committee. The new law also prevents the governor from implementing a Medicaid expansion program waiver (or requesting other types of Medicaid waivers or waiver amendments) without legislation enacted specifically directing the submission of the waiver request.

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  37. 2017 Wisconsin Act 370 (S.B. 886), enacted December 14, 2018, https://docs.legis.wisconsin.gov/2017/related/acts/370

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  38. Tony Evers, Executive Order 3 (The State of Wisconsin Office of the Governor, January 2019), https://docs.legis.wisconsin.gov/code/executive_orders/2019_tony_evers/2019-3.pdf

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  39. Jessie Opoien, “Tony Evers Signs Executive Orders Related To Medicaid Expansion, Pre-Existing Conditions”

    The Cap Times (January 8, 2019), https://madison.com/ct/news/local/govt-and-politics/election-matters/tony-evers-signs-executive-orders-related-to-medicaid-expansion-pre/article_dc157972-0a5e-52b3-a0d7-fd4940acdbe3.html

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  40. Portland Press Herald, “2017 Maine Election Results,” November 2017, https://www.pressherald.com/2017-election-results/

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  41. Secretary of State Matthew Dunlap, “Maine Citizen’s Guide to the Referendum Election,” (Augusta, ME: Office of the Secretary of State, November 2017), https://www.maine.gov/sos/cec/elec/upcoming/citizensguide2017.pdf

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  42. Ballotpedia, “Maine Question 2, Medicaid Expansion Initiative (2017),” https://ballotpedia.org/Maine_Question_2,_Medicaid_Expansion_Initiative_(2017)#cite_note-35

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  43. Idaho Secretary of State’s Office, “2018 Proposed Ballot Initiatives,” accessed February 18, 2019, https://sos.idaho.gov/elect/inits/2018/init03.html

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  44. Idaho Secretary of State, “November 6, 2018 General Election Results,” accessed February 18, 2019, https://sos.idaho.gov/elect/results/2018/General/statewide_totals.html

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  45. Nebraska Secretary of State, “Initiative Measure 427,” Proposed Amendments & Initiatives, Sample Ballot General Election, November 6, 2018, http://www.sos.ne.gov/elec/2018/pdf/2018-General-Ballots/English%20-%20Initiative%20Measure%20427.pdf

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  46. Nebraska Secretary of State, “Official Results: General Election - November 6, 2018,” updated December 2018, https://electionresults.sos.ne.gov/resultsSW.aspx?text=Race&type=SW&map=CTY

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  47. State of Utah, Proposition Number 3 Ballot Title and Impartial Analysis, https://elections.utah.gov/Media/Default/2018%20Election/Issues%20on%20the%20Ballot/Proposition%203%20-%20Ballot%20Title%20and%20Impartial%20Analysis.pdf

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  48. State of Utah, Office of the Lieutenant Governor, 2018 General Election Results, https://elections.utah.gov/Media/Default/2018%20Election/2018%20General%20Election%20Canvass.pdf

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  49. Bruce Jaspen, “More Red State Medicaid Ballot Measures May Emerge In 2020,” Forbes (November 25, 2018),

    https://www.forbes.com/sites/brucejapsen/2018/11/25/medicaid-ballot-measures-may-emerge-in-more-red-states-for-2020/#6c5f9e6f6517

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  50. Annie Melia, Ballot Initiative Requirements in Non-Medicaid Expansion States (Health Management Associates, November 2017), https://www.healthmanagement.com/blog/ballot-initiative-requirements-non-medicaid-expansion-states/

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  51. Four states have restrictions on how soon state legislators can repeal or amend initiative statutes—ranging from two to seven years. Six states have restrictions on how large of a supermajority vote is required in the legislature to repeal or amend initiative statutes. Only two states (Arizona and California) have voter approval requirements for changes to or the repeal of citizen-initiated state statutes.

    Ballotpedia, “Legislative Alteration,” (Ballotpedia, accessed February 12, 2019), https://ballotpedia.org/Legislative_alteration#No_restrictions

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  52. S.B. 96, State of Utah, 2019 General Session (2019). https://le.utah.gov/~2019/bills/static/SB0096.html

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  53. State of Utah, Proposition Number 3 Ballot Title and Impartial Analysis, https://elections.utah.gov/Media/Default/2018%20Election/Issues%20on%20the%20Ballot/Proposition%203%20-%20Ballot%20Title%20and%20Impartial%20Analysis.pdf

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  54. S.B. 96, State of Utah, 2019 General Session (2019). https://le.utah.gov/~2019/bills/static/SB0096.html

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  55. Kaiser Family Foundation, Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State

    (Washington, DC: Kaiser Family Foundation, February 2019),https://www.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1115-waivers-by-state/

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  56. S.B. 1100, Sixty-Fifth Legislature of the State of Idaho, 2019 Regular Session, accessed on February 19, 2019, https://legislature.idaho.gov/wp-content/uploads/sessioninfo/2019/legislation/S1100.pdf

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  57. The expansion measure passed in Maine required the state to submit a SPA within 90 days of the “effective date” of the bill and implement the expansion within 180 days of the “effective date.” However, Former Governor LePage refused to implement the expansion, arguing that the Legislature needed to fully fund the expansion first without increasing taxes, using the rainy day fund, or reducing services to the elderly or people with disabilities. LePage vetoed a $60 million expansion funding bill passed by the Legislature in June 2018, arguing that it contained one-time budget gimmicks. The Governor ultimately complied with a Maine Supreme Judicial Court order to submit an expansion state plan amendment (SPA) to the federal government in September 2018, but he accompanied it with a letter asking CMS to reject the SPA.

    Secretary of State Matthew Dunlap, “Maine Citizen’s Guide to the Referendum Election,” (Augusta, ME: Office of the Secretary of State, November 2017), https://www.maine.gov/sos/cec/elec/upcoming/citizensguide2017.pdf

    State of Maine Office of Governor Paul R. LePage, Governor LePage Issues Statement on Medicaid Expansion, (November 2017), http://www.maine.gov/tools/whatsnew/index.php?topic=Gov+News&id=771214&v=article2011

    Joe Lawlor, “LePage Files Court-Ordered Plan to Expand Medicaid in Maine—and Asks Feds to Reject It,” Press Herald (September 4, 2018), https://www.pressherald.com/2018/09/04/lepage-files-plan-to-expand-medicaid-but-asks-feds-to-reject-it/

    Governor Paul LePage, Letter to Secretary Azar and Administrator Verma, August 2018, http://mediad.publicbroadcasting.net/p/mpbn/files/201809/2018-8-31_gov_letter_to_sec_azar_and_admin_verma_re_me_state_plan_amendm....pdf

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  58. Janet Mills, Executive Order Number 1, Office of the Governor of Maine, (January 3, 2019), https://www.maine.gov/governor/mills/sites/maine.gov.governor.mills/files/inline-files/Executive%20Order%201.pdf

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  59. Regan v. Denney, Idaho Supreme Court Petition for Review, https://idahofreedom.org/wp-content/uploads/2018/11/Petition-for-Review-3.pdf

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  60. Regan v. Denney, Idaho Supreme Court Docket No. 46545, Opinion Filed February 5, 2019,

    https://isc.idaho.gov/opinions/46545.pdf

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  61. Montana Secretary of State, Initiative No. 185, https://sosmt.gov/Portals/142/Elections/archives/2010s/2018/I-185.pdf

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  62. Michael Ollove, “This State Wanted To Expand Healthcare For The Poor. Big Tobacco Helped To Kill That Idea,”

    The Huffington Post (December 28, 2018), https://www.huffingtonpost.com/entry/lone-medicaid-expansion-defeat-offers-lessons-for-other_us_5c191d15e4b01954d9b06909

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  63. Ballotpedia, “Oregon Measure 101, Healthcare Insurance Premiums Tax for Medicaid Referendum (January 2018),” accessed February 2019, https://ballotpedia.org/Oregon_Measure_101,_Healthcare_Insurance_Premiums_Tax_for_Medicaid_Referendum_(January_2018)#cite_note-2

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  64. Oregon Secretary of State, “January 23, 2018, Election Abstract of Votes,” Amended February 22, 2018, https://sos.oregon.gov/elections/Documents/results/january-2018-results.pdf

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  65. Kaiser Family Foundation, Medicaid Expansion in Pennsylvania: Transition from Waiver to Traditional Coverage (Washington, DC: Kaiser Family Foundation, August 2015), https://www.kff.org/medicaid/fact-sheet/medicaid-expansion-in-pennsylvania/

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  66. There is ongoing litigation in Kentucky over the Kentucky HEALTH Section 1115 waiver, which includes approval to transition Kentucky’s expansion program from SPA to Section 1115 waiver authority. For more information, see:

    MaryBeth Musumeci, A Guide to the Lawsuit Challenging CMS’s Approval of the Kentucky HEALTH Medicaid Waiver, (Washington, DC: Kaiser Family Foundation, January 2018), https://www.kff.org/medicaid/issue-brief/a-guide-to-the-lawsuit-challenging-cmss-approval-of-the-kentucky-health-medicaid-waiver/

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  67. State of Louisiana Executive Order No. JBE 16-01. http://gov.louisiana.gov/assets/docs/Issues/JBE1601.pdf

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  68. Ark. Code § 20-77-2401 et seq., http://law.justia.com/codes/arkansas/2014/title-20/subtitle-5/chapter-77/subchapter-24/.

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  69. Louise Norris, “Arkansas and the ACA’s Medicaid Expansion,” (Healthinsurance.org, November 2018), https://www.healthinsurance.org/arkansas-medicaid/

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  70. H.B. 4714, Public Act 107, Michigan Legislature (enacted 2013). https://www.legislature.mi.gov/documents/2013-2014/publicact/pdf/2013-PA-0107.pdf

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  71. Centers for Medicare and Medicaid Services, “Healthy Michigan,” (accessed February 19, 2019), https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/?entry=8517

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  72. Kaiser Family Foundation, Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State

    (Washington, DC: Kaiser Family Foundation, February 2019),https://www.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1115-waivers-by-state/

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  73. Bryce Ward and Brandon Bridge, The Economic Impact of Medicaid Expansion in Montana: Updated Findings, (Missoula, MT: BBER, January 2019).

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  74. H.B. 735, Louisiana Legislature, 2018 Regular Session, https://www.billtrack50.com/BillDetail/973988/2838

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  75. KanCare Expansion Bill proposed by Governor Laura Kelly, January 2019, https://governor.kansas.gov/wp-content/uploads/2019/01/KanCare-Expansion-Bill-Final.pdf

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  76. S.B. 1100, Sixty-Fifth Legislature, Idaho Legislature 2019 Session, https://legislature.idaho.gov/wp-content/uploads/sessioninfo/2019/legislation/S1100.pdf

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  77. “Proposition Number 3,” Utah Elections, accessed November 5, 2018, https://elections.utah.gov/Media/Default/2018%20Election/Issues%20on%20the%20Ballot/Proposition%203%20-%20Ballot%20Title%20and%20Impartial%20Analysis.pdf

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  78. Biggs v. Betlach, Supreme Court of the State of Arizona, No. CV-17-0130-PR, Filed November 17, 2017,

    https://www.azcourts.gov/Portals/0/OpinionFiles/Supreme/2017/Biggs%20v.%20Betlach%20Opinion.pdf?ver=2017-11-17-095423-747

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  79. House Concurrent Resolution No. 75, Louisiana Legislature 2015 Regular Session, http://www.legis.la.gov/legis/ViewDocument.aspx?d=957411

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  80. Dylan Matthews, “The Republican Plan to Slash Medicaid, Explained,” Vox (March 10, 2017), https://www.vox.com/policy-and-politics/2017/3/10/14847218/medicaid-ahca-republican-obamacare-replacement

    Virginia Acts of Assembly, 2018 Special Session I, Approved June 7, 2018, https://budget.lis.virginia.gov/get/budget/3619/

    S.B. 96, State of Utah, 2019 General Session (2019). https://le.utah.gov/~2019/bills/static/SB0096.html

    S.B. 1100, Sixty-Fifth Legislature, Idaho Legislature 2019 Session, https://legislature.idaho.gov/wp-content/uploads/sessioninfo/2019/legislation/S1100.pdf

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