Democrats won pretty much everywhere in Tuesday’s election, but there is a reason beyond the effect President Donald Trump has on their fortunes for Republicans to be unnerved by the results. It has to do with both politics and policy, and it could mean trouble for them in 2018.
I’m talking about Medicaid. As you might have seen, voters in Maine approved a ballot initiative Tuesday to accept the Affordable Care Act’s expansion of Medicaid by a margin of 59 percent to 41 percent. The expansion has been resisted by Republican Paul LePage, to whom I fondly refer as America’s Worst Governor.
Now LePage is actually proclaiming that he’ll refuse to implement the new law unless the legislature funds it. Even though the federal government will pick up 90 percent of the cost of the expansion, Republicans control the state senate by a one-vote margin and may follow LePage’s lead and refuse to fund the expansion, denying health coverage to tens of thousands of their constituents.
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If you’re looking for a microcosm of the national picture on what has become one of the most important functions the government serves, you couldn’t do much better. The public wants Medicaid, but Republicans hate it and will do everything they can to undermine it.
Both sides of that coin have never been more apparent than they are now. Just Tuesday, Seema Verma, the Trump administration official who oversees Medicare and Medicaid, announced that the administration will now encourage states to adopt work requirements for the program, even though most Medicaid recipients already come from households where someone is employed.
The real point of this is to make recipients jump through more hoops and reduce the number of people on the program. In fact, the Trump administration is explicitly rejecting the idea that the purpose of Medicaid is to make sure people have health insurance. In Verma’s speech, she said she wants to get people off Medicaid. “The thought that a program designed for our most vulnerable citizens should be used as a vehicle to serve working age, able-bodied adults does not make sense,” she said. Allowing states more flexibility to kick people off the program will enhance “the dignity and respect of high expectations.”
That’s the GOP position, and Republicans do have reason to be worried about it. They’ve been alarmed by Medicaid’s growth in recent years, since the program (along with the Children’s Health Insurance Program, which is essentially a Medicaid subsidiary) now provides insurance to more than 74 million Americans. Since many Republicans would literally rather see someone have no insurance than get health coverage from the government, they find that to be an abomination.
Yet the public does not share these views. Polls show that Medicaid is spectacularly popular, even with Republican voters. In Kaiser Family Foundation polls, 74 percent of Americans have a favorable view of the program (including 61 percent of Republicans) and 87 percent want its funding increased or kept the same (including 76 percent of Republicans). In states that refused the expansion of Medicaid, 73 percent have a favorable view of the program. It was the fact that their repeal bills would have slashed Medicaid as much as any other factor that led to their demise.
That brings us to the implications of the Maine vote for the future. Even though Republican officials in 19 states refused the expansion - in which the federal government would pay for almost all the cost of insuring their poor citizens - voters in those states don’t seem to agree with the choice their representatives made. Which means that if activists can put measures on the ballots in those states to accept the expansion, they may succeed not only in changing the policy but also in shaping the debate and getting more Democratic-friendly voters to the polls.
Will that work? I checked in with Patrick Willard, who directs outreach for the liberal group Families USA. He told me there’s already an active effort for a 2018 ballot measure in Utah, where advocates have submitted the text of a proposed initiative and are gathering signatures. There are also activists interested in putting together ballot measures in Idaho, Missouri, Nebraska and possibly Wyoming.
“There’s a recognition of the popularity of the program,” Willard said, adding that “people want to figure out a way to break through the stalemate” that occurs when state legislators refuse to accept the expansion, sometimes even over the objections of their Republican governors.
Meanwhile, Ralph Northam’s victory in Virginia has reinforced the idea that health care and Medicaid can be powerful ballot box issues for Democrats. Virginia voters were asked in exit polls what issues were most important to them in deciding their vote, and as The Post put it: “39 percent said health care, far more than any other issue. And health-care focused voters favored Northam by a giant 77 percent to 23 percent margin.”
The context is that Gov. Terry McAuliffe, D, has been fighting with Virginia’s Republican legislature over Medicaid expansion for years. Depending on how the recounts turn out, Democrats could take control of the House of Delegates, and if they can convince just one Republican in the state senate (where Republicans hold a 21 to 19 advantage) to support the expansion, Virginia could be the next state to validate the idea that health coverage is a right.
So in the coming days, Republican-controlled states will start submitting waivers to the federal government, seeking to chisel away at their Medicaid programs, making it harder to enroll and increasing the number of their citizens who lack insurance. Meanwhile, the Democratic Party is going to continue shifting left on health care, as the support for some form of universal coverage becomes non-negotiable for candidates with national ambitions - and gains public support.
And if Democrats can get more Medicaid expansion measures on the ballot, they could turn some red states a little bluer. It’s just one more thing for Republicans to worry about.
Paul Waldman is a contributor to The Plum Line blog at the Washington Post and a senior writer at The American Prospect. Follow him on Twitter @paulwaldman1.