Nebraska voters will decide next month whether Medicaid coverage should be extended to an estimated 90,000 adult Nebraskans, most of whom work in low-paying jobs.
They include food service and retail sales workers who do not qualify for Medicaid assistance now and cannot afford to purchase private health care insurance.
After seven years of frustration and failure in the Legislature, supporters launched an initiative petition drive that collected more than 100,000 signatures statewide to place the issue on the November ballot and hand the decision over to Nebraska voters.
While supporters argue that the proposal would fuel an economic boom in the state by accessing more than a billion dollars in federal funding while extending needed health care coverage to Nebraskans described as the working poor, opponents contend that state matching fund costs would disrupt the state budget and crowd out other spending priorities.
Recent estimates from the legislative fiscal office envision $1.3 billion in federal funding flowing into the state during the first three years of the new program, with state matching fund costs estimated to total $90.8 million over that period.
(The Nebraska Department of Health and Human Services has separately estimated far higher three-year state costs of more than $140 million.)
Supporters argue that the program will "essentially pay for itself" in terms of generating new economic activity that would include jobs created and sustained, along with rural hospitals and clinics saved.
Gov. Pete Ricketts has warned that it could "crowd out funding for essential priorities like property tax relief and K-12 education," according to a statement released by Matthew Trail, communications director for the governor's re-election campaign.
Meg Mandy, the initiative's campaign manager, said there are ready sources of revenue available — including new revenue from the state sales tax that is about to be applied to online purchases — and that opponents are resorting to "scare tactics."
To reach the November ballot, the initiative first had to clear a lawsuit filed by officials associated with the Republican Party.
Sen. Adam Morfeld of Lincoln and former Lincoln Sen. Kathy Campbell have been leaders in the unsuccessful efforts to gain legislative approval for Medicaid expansion.
"It's hard to stay healthy without health care insurance," Morfeld has said.
Without health care insurance, people "wait far too long" to receive treatment, Campbell has pointed out.
And that, in turn, leads to more serious and expensive health care challenges that can result in uncompensated care whose costs then are reflected in private health care insurance rates paid by all Nebraskans, Campbell noted during a celebration marking conclusion of the successful petition drive this summer.
Thirty-two states and the District of Columbia have expanded Medicaid, and the issue is in play now in Utah, Idaho and Montana as well as Nebraska.
Financial supporters of the initiative in Nebraska have included Nebraska Appleseed and the Nebraska State Education Association.
Americans for Prosperity and the Platte Institute have lined up on the other side.
Every dollar spent on Medicaid expansion is one less that is available for property tax relief, K-12 school support or funding for the University of Nebraska, Platte Institute CEO Jim Vokal of Omaha said.
In every state that has expanded Medicaid, costs have exceeded projections, he said, and "the truly vulnerable sometimes get crowded out."
Americans for Prosperity state director Jessica Shelburn argues that the initiative proposal would "make a bad problem worse by further straining a broken Medicaid program that already struggles to provide quality health care services for Nebraska's most vulnerable citizens."
The vast majority of current Medicaid recipients are children and the elderly.
Supporters of Medicaid expansion are mounting an aggressive campaign after organizing statewide for the petition effort. They gathered signatures in all 93 counties during a million-dollar drive.
An appealing argument in rural Nebraska has been protection for rural hospitals whose financial future is at risk.
"If the hospital goes away, it's hard for a town to thrive and survive," Mandy pointed out.
Supporters argue that Medicaid expansion could create and sustain 10,000 new jobs in Nebraska while reducing medical bankruptcies.
The expanded coverage would go to Nebraskans whose jobs generally earn them less than $17,000 a year, Mandy said.
"These are people working in diners and food courts, on construction job sites or in part-time jobs teaching children and caring for the elderly," Patrick Willard, senior director of state and national strategic partnerships for Families USA, said in releasing a study last month identifying the range of workers in Nebraska who would be impacted.
Supporters of the initiative are encouraged by the results of a similar initiative petition effort in 2014 to seek a vote on a proposal to increase the state minimum wage rate in Nebraska after the Legislature failed to act.
That proposal ultimately was approved by Nebraskans on a vote of 311,401 to 212,215, with a majority vote cast in 72 of the state's 93 counties.