Medicaid
Medicaid Expansion: closing the deal
Direct democracy has gotten six more states to expand, but reformers will need to win legislative elections to bring Obamacare’s most effective reform to all 50 states
Fresh off two major victories in Oklahoma and Missouri, 38 states and Washington DC have now embraced the Affordable Care Act’s Medicaid Expansion.
Progress has surprisingly rapid during the Trump administration, with seven more states expanding since 2017. But getting all 50 states onboard is going to require new tactics from activists.
Expansion, which extends eligibility to all adults in households with incomes up to 138 percent of the Federal Poverty Line, has been the ACA’s most successful initiative, accounting for getting health insurance to more than 12 million of the 20 million people covered by the law’s provisions.
Since the start of the Trump administration, seven states have expanded. Only one, Virginia, has gone through the internal government route of getting bills passed through the state legislature and getting them signed by the governor.
The other six — Maine, Idaho, Utah, Nebraska, Oklahoma and Missouri — have expanded through voter-led initiatives.
The initiative is a form of direct democracy that allow voters to circulate petitions with a proposal. If they gather enough signatures, the proposal goes on the ballot. If enough voters (usually a majority, but not always) approve, the proposal becomes law. Some states allow petitions for legislation, some allow petitions to changes the constitution and some allow both.
As Phillip Rocco and other scholars have noted, activists backing Medicaid expansion have found voter initiatives a particularly effective way to outflank Republican governors and state legislatures, because Medicaid tends to be more popular with the electorate at large than with Republican politicians. As a result, expansion can win statewide even in places with extremely conservative governments.
The good news is for expansion proponents is that they have a perfect record with voter initiatives: six wins in six tries.
The bad news is that they are running out of states they can use the initiative process to pass expansion.
Of the twelve states holding out from Medicaid expansion, only four — Wyoming, South Dakota, Mississippi and Florida — remain that have options for voter-led initiatives.
As shown in Table 1, these four states have only 520,000 of the more than 2.1 million people that fall into the Medicaid gap — people who don’t qualify for either traditional Medicaid or subsidies to purchase individual commercial plans on the state exchanges — exist in these four states. The biggest prize by far is Florida, which has more than 390,000 who lack health insurance
But in the other states, which include big ones like North Carolina, Georgia and Texas, activists are going to have to win the old-fashioned way: Get more Democrats elected to state legislatures.
Despite gerrymandering, which has limited Democratic power considerably, activists might have a chance in some states. Conservative Republicans beating moderate ones in Kansas primaries might dampen hopes for expansion in that state. However, Democrats have real chances to take statehouse chambers in both North Carolina and Texas, which would greatly increase their leverage and perhaps allow for some sort of expansion to slip through. Retaining the governorship in North Carolina would help as well.
Winning the presidency and both houses of Congress would also open the door to national reform as well. Democratic nominee Joe Biden has proposed a public option that would take effect in states that don’t expand Medicaid, offering a public insurance program that would be available anyone who would otherwise qualify for expanded Medicaid. If the Democrats hold the House and win the Senate, a form of that plan might become reality.
There are two morals of this story. First, reform doesn’t take place overnight — especially in decentralized societies. After all, it took 17 years after the passage of Medicare and Medicaid in 1965 for every state to develop its own Medicaid program. The reformers, leaders and activists pushing change at the state level have been valuable in decades-long fights over everything from health care and environmental laws to working conditions, women’s rights and old-age pensions.
The second moral is, as always, that elections matter, whether they be direct voter initiatives or for the state legislature.
Keep that in mind as you ponder your options this November.
