Even as President Trump launches new attacks on the Affordable Care Act, voters in four deep red states are poised this fall to expand access to government Medicaid coverage through the 2010 law, often called Obamacare.
Nebraska last week became the fourth state to qualify a Medicaid expansion initiative for the November ballot, giving voters there the chance to do an end-run around the state’s Republican political leaders who have fought the healthcare law for years.
Similar measures have already qualified in Idaho and Utah, where GOP officials for years have resisted Medicaid expansion, and in Montana, where a Medicaid expansion begun in 2016 is slated to sunset next year unless the state moves to extend it. Polling in the states shows widespread public support.
“Healthcare is the most powerful force in politics today,” said Jonathan Schleifer, executive director of the Fairness Project, a liberal activist group that is helping fund the Medicaid expansion efforts. “These ballot measures are a game changer that is allowing us to go into states where politicians are opposed. … If we win in these states, we can win everywhere.”
The unprecedented number of Medicaid ballot measures underscores the enduring popularity of the half-century-old government health insurance program for the poor, which -- along with the related Children’s Health Insurance Program — now covers more than 70 million Americans.
In California, which was among the first group of states to expand Medicaid coverage in 2014 through the healthcare law, more than 12 million adults and children are now covered by the two programs.
The new state initiatives also represent another challenge to the president and his GOP allies in Congress, who continue to champion moves to roll back the law and the sweeping coverage gains it has made possible.
The Trump administration has endorsed a broad legal challenge from a group of conservative states led by Texas that are arguing in federal court that the whole law should be invalidated.
Trump recently boasted at a Cabinet meeting that his administration has been dismantling the healthcare law “piecemeal” following the collapse last year of the GOP effort in Congress to repeal it. “It’s going to be gone pretty soon,” the president predicted.
But across the country, there is growing evidence that most Americans, even in many conservative states, want the health protections made available by the health law.
This spring, Virginia moved to expand eligibility for its Medicaid program, after a group of Republican lawmakers joined Democrats in the GOP-controlled legislature to back expansion.
And last year, more than 59% of voters in Maine backed a Medicaid expansion initiative, repudiating Republican Gov. Paul LePage’s longstanding opposition. LePage, a strong Trump ally, continues to resist, despite a court order to abide by the initiative.
Medicaid is a pillar of the 2010 law’s program for guaranteeing coverage, and it has helped drive a historic drop in the nation's uninsured rate. Surveys indicate that at least 20 million previously uninsured Americans have gained coverage since 2014, though polling suggests the coverage gains have slowed or even reversed since Trump took office.
The law makes hundreds of billions of federal dollars available to states to extend Medicaid coverage to poor adults, a population that had been largely excluded from the safety net program.
Medicaid eligibility historically was limited to vulnerable populations, such as low-income children, pregnant women, the elderly and people with disabilities.
Most states moved to expand eligibility as soon as the healthcare law made additional federal aid available. To date, 33 states and the District of Columbia have elected to expand.
But GOP opposition — concentrated in the Deep South and the Great Plains — has left some 2.2 million low-income Americans without insurance in the states that haven’t expanded Medicaid, according to an analysis by the nonprofit Kaiser Family Foundation.
Many Republicans have argued that the program is unaffordable and ineffective, though a growing body of research shows Medicaid significantly improves poor Americans' access to vital medical care.
A new study published this month in the journal Health Affairs, for example, found a dramatic increase in the prescription fills for diabetes drugs in states that expanded Medicaid, compared with states that did not expand, suggesting the coverage is helping many low-income diabetics get the medications they need.
Stonewalled in conservative state legislatures around the country, Medicaid supporters have instead found a receptive audience among voters.
The signature-gathering campaigns to get Medicaid-expansion measures on the ballot in Idaho, Montana, Utah and Nebraska delivered substantially more signatures than were needed. And organizers said they had little trouble finding supporters.
“People understand this is about helping people who are dealing with chronic health issues or cancer treatment or epilepsy,” said Meg Mandy, campaign manager for the Insure the Good Life Medicaid campaign in Nebraska. “They see this can happen to a small-business owner or a mom who is going back to school.”
The Nebraska campaign, which needed about 85,000 valid signatures to qualify for the November ballot, turned in 135,000.
In Utah, nearly two-thirds of those surveyed by Utahpolicy.com backed the Medicaid initiative there.
The Medicaid expansion measure in Idaho drew similarly strong support in a December poll commissioned by expansion supporters.
The Idaho measure also has been backed by more than half a dozen Republican state lawmakers, including state Sen. Shawn Keough, who chairs the chamber’s finance committee. Keough called Medicaid expansion “the fiscally responsible thing to do and … the humanitarian thing to do.”
Toni Lawson, vice president for government affairs at the Idaho Hospital Assn., said proponents have stressed that the state is losing millions in federal tax dollars by not expanding coverage. “That message resonates with Republicans and fiscal conservatives,” she said.
A handful of GOP lawmakers in Nebraska and Utah have provided critical support to the Medicaid measures in those states as well.
In all four states, the initiatives have also picked up broad support from patient advocacy groups, physician and hospital associations and many churches.
The political tide is now so strong, in fact, that Nebraska’s Republican governor, a longtime foe of Medicaid expansion, has not publicly opposed the Medicaid measure, and the two GOP politicians vying to be governor in Idaho next year have signaled they will abide by the results of the initiative there.
Republican Utah Gov. Gary R. Herbert has previously supported Medicaid expansion, though his proposal was blocked in the GOP-controlled legislature.
Montana Gov. Steve Bullock is a Democrat who has strongly endorsed keeping the state’s Medicaid expansion.
Elsewhere around the country, Medicaid supporters are already eyeing potential ballot initiatives in other red states, including Florida, Missouri, Mississippi, Oklahoma, South Dakota and Wyoming.
Medicaid ballot initiatives are not possible under state election rules in the remaining eight states that have not expanded Medicaid: Alabama, Georgia, Kansas, North Carolina, South Carolina, Tennessee, Wisconsin and Texas, which has the highest uninsured rate in the nation.