As the dust settles on the 2018 midterm elections, pundits and politicians will endlessly debate what the results mean for the country. Talking heads will read the electoral “tea leaves,” and pontificate on a “Blue Wave,” or “Red Wall,” and what it all means for 2020. However, with some races too close to call, multiple recounts, and the ever-present reality of gerrymandering and voter suppression, we may never agree on the “meaning” of 2018.
What is clear is that health care won. Preserving access to affordable health care was a key winning message across the country. Voters in three deep red states, Idaho, Nebraska, and Utah, approved ballot initiatives that expanded Medicaid under the Obama administration’s landmark Affordable Care Act (ACA). This is a stunning reversal from the last few election cycles where baseless but nevertheless effective attacks on the progressive health care law propelled conservative victories in Congress, state legislatures, and governors’ mansions. In contrast, the result of last night’s votes to expand Medicaid will offer more than 300,000 low-income people access to quality health care.
The health care implications of the vote are staggering. Medicaid expansion leads to greater access to an array of health care services, from primary care to substance abuse treatment. People with chronic conditions, such as diabetes and HIV/AIDS experience better health outcomes as they are more likely to start and continue treatment and new research shows that Medicaid expansion results in better access to surgery and higher quality surgical care. Less tangible, but no less important is the financial well-being connected with Medicaid expansion. People in expansion states report having an easier time paying their medical bills, and carrying less debt.
The political ramifications of the 2018 midterm elections are also worthy of noting. The real possibility of expanding Medicaid in Republican controlled states suggests that health care is an important issue for voters, even in conservative corners of the country. Republican statehouses in Boise, Lincoln, and Salt Lake City have blocked Medicaid expansion for years, towing the anti-Obamacare line that propelled the Republicans to dominance earlier this decade. But the scare tactics of “socialized medicine” and “Obamacare Death Panels” seem to be losing potency. Voters, even those who cast ballots for Republicans, are changing their views of Medicaid and the ACA.
The potential to expand Medicaid demonstrates that people across the country are recognizing the need and opportunity to have quality health care through the ACA and Medicaid expansion, and they are taking steps to get it. The campaigns started from the ground up, with grassroots organizing by local residents. Strict rules governing ballot initiatives meant that organizers needed to build strong support at the local level, even in conservative, rural areas that have long supported candidates who vehemently oppose both Medicaid and the ACA. Organizers then built networks of allies including organizations representing physicians, hospitals, chambers of commerce, patient advocates, and progressive groups. Together they made the powerful case that Medicaid expansion makes sense, for patients, providers, and the economy of the states.
As a non-profit that fights to protect and expand access to quality health care, the National Health Law Program is encouraged by these wins and hopes that they signal a change in the political calculus. For most of the last decade, health care has been wielded as a political battle-ax, and opposition to Medicaid seen as a political asset in red states. That political truism has lost its force. For example, in Idaho, the outgoing governor, Republican Butch Otter, endorsed the Medicaid expansion ballot initiative last week. Meanwhile, Democratic gubernatorial victories in Kansas, Maine and Wisconsin could lead to rapid expansion of Medicaid, a position popular with voters, but blocked by Republican legislatures or governors. (Mainers voted to expand Medicaid last year, but their outgoing GOP governor has obstructed the process). Medicaid expansion in these six states could produce the largest growth in the program since the passage of the Affordable Care Act. Therefore, if nothing else, a “Medicaid Wave” is building.
Perhaps the most important fallout from last night will be what these victories mean for the ongoing attacks on the integrity of Medicaid and the ACA. With the House under Democratic control, further attempts to repeal the ACA and institute Medicaid block grants will at least be on hold for two more years, while Trump’s illegal attempts to weaken Medicaid with Section 1115 Medicaid waivers might become even more unpalatable. Such a show of popular support for Medicaid in “Trump country” might give him and his allies at HHS pause as they continue their crusade to decimate Medicaid.