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

A collection of those little “I voted” stickers they hand out at polling places to people who’ve done their civic duty.
A collection of those little “I voted” stickers they hand out at polling places to people who’ve done their civic duty.
If you want the Affordable Care Act’s Medicaid expansion, in most states that haven’t expanded you have to vote for politicians who will enact it instead of voting directly for it. Photo by Element5 Digital on Unsplash

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.


Direct democracy gives citizens in some states a work-around to access Obamacare’s most effective way to extend health insurance coverage, but even winning a vote leaves roadblocks to expanded Medicaid

Some state constitutions allow a direct citizen vote on whether to expand Medicaid. However, winning the vote is only the first step to overcome the elected state officials who were blocking it in the first place. Photo by Element5 Digital on Unsplash

The Affordable Care Act’s Medicaid expansion, which extended Medicaid coverage to all adults with incomes below 138 percent of the federal poverty line ($36,156 for a family of 4 in 2020), has proven the single most effective tool in the ACA’s box to cover the uninsured.

Of the 20 million people in the United States who gained coverage through the ACA by 2019, roughly half acquired insurance through Medicaid expansion. Despite being coverage for people without access to anything else, Medicaid isn’t substandard; rather, it tends to be comprehensive high-quality insurance. …

Because the ACA greatly improved non-employer insurance options, more Americans will have access to health coverage during the pandemic

Sure, the Affordable Care Act has leaks, but it’s helping the U..S health system keep a lot of people dry from the deluge of the COVID-19 economic crisis. Photo by Matthew T Rader on Unsplash

The United States is currently starting down a health care disaster: Between the COVID-19 pandemic and the accompanying economic collapse, tens of millions of Americans are losing both their jobs and their employer health insurance. Naturally, this series of unfortunate events takes place at the precise moment it would really be helpful for those same Americans to have access to comprehensive health care.

But things could be much, much worse. Thanks to the passage of some rather far-sighted policy reforms that took place starting in 2010, and the failure of some very shortsighted proposals in 2017, many, and likely most…

On June 30, voters can give 178,000 state residents access to health care — just in time to respond to a pandemic

Trust us, Woody Guthrie would have supported Oklahoma Medicaid expansion. Photo by Katie Moum on Unsplash

The COVID-19 pandemic, the economic collapse, and a life-altering presidential election six months from now dominate current headlines. But there’s a very important election flying under the radar on June 30 in Oklahoma, where State Question 802 offers voters a chance to accept the Affordable Care Act’s Medicaid expansion.

If passed, the initiative would provide health coverage to an estimated 178,000 state residents who currently lack it.

To paraphrase a certain former Vice President, that’s a big deal.

Medicaid is the joint state-federal program created in 1965 that traditionally covers the poor and disabled. Before the Obama era, Medicaid was…

Administrative roadblocks created by Republicans hinder pandemic response

Photo by uomo libero on Unsplash

Today, we speak of pigs and pythons: Specifically, we discuss the mechanics of what moves a whole pig through the intestinal tract of a python.

It’s all a metaphor for governmental capacity, not serpentine digestion.

Like most pithy phrases, this one was stolen from another author. Michael Grunwald memorably used it in his book The New New Deal, about the American Recovery and Reinvestment Act (ARRA) of 2009 — more commonly known as the Obama stimulus.

The idea is passing legislation is only the first part of policymaking. In order to execute it, governmental capacity has to be available to…

The original Medicaid program took 16 years to be adopted in all 50 states, so keep playing the long game on Medicaid Expansion

A big tortoise ambles toward the screen, possibly hoping you have a banana, but certainly very determined to expand Medicaid.
A big tortoise ambles toward the screen, possibly hoping you have a banana, but certainly very determined to expand Medicaid.
Photo by Dušan Smetana on Unsplash

The pace of the implementation of the Affordable Care Act has been a justifiable source of frustration — especially the foot-dragging by Conservative states on the ACA’s Medicaid Expansion.

Since 2012, when the U.S. Supreme Court gave state officials a choice to take or reject expansion, which would extend Medicaid coverage to everyone in households earning below 138 percent of the poverty line, many state Republican elected officials — egged on by hard-edge ideological groups — have dug in their heels against providing health coverage for their constituents.

As a result, expanding Medicaid in numerous Republican-controlled states has seemed a…

Big new social programs are memorable, but the history of Medicaid shows how a series of small improvements can be just as transformative.

A walker ascends a staircase one step at a time
A walker ascends a staircase one step at a time
Photo by Bruno Nascimento on Unsplash

You’ve probably never head of the Deficit Reduction Act of 1984.

The 1985 Consolidated Omnibus Reconciliation Act doesn’t exactly roll off the tongue either.

And the 1987, 1989 and 1990 Omnibus Reconciliation acts sound like unnecessary sequels so ponderous that even Kevin Costner and his accountant turned down offers to direct.

But combined, these bills and several others like them quietly transformed Medicaid, the public health care program that primarily covers poor Americans, from an afterthought into a comprehensive, broad-based and popular social safety-net program. That’s something Democrats should keep in the back of their minds as they debate what…

Patrick O'Mahen

PhD Political Scientist; health policy researcher at the VA; former newspaper editor. Good civil servant: I share my opinions on my own time and dime

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