North Carolina’s Republican-led legislature last week approved the expansion of Medicaid to more low-income adults, leaving only 10 states that continue to reject the federal government’s incentives under the Affordable Care Act. Medicaid expansion, aimed at adults who make too much money to qualify for conventional Medicaid but not enough to receive subsidized insurance through ACA marketplaces, has had a bigger effect than any other policy in reducing the country’s uninsured population. Expect the last 10 states, most of which are strongly Republican, to eventually sign on, too.
That’s not the way things normally work in this era of partisan polarization, where the nation is moving to two sets of laws, one for Republican states and one for their Democratic counterparts, on many policy questions where the federal government allows choice. We no longer expect California and Texas to converge voluntarily on the same abortion policy or the same rules about labor rights or the same laws about school choice. And yet North Carolina now joins Idaho, Arkansas and several other Republican states in adopting the reform. (1) And it’s just a matter of time before Texas, Florida and the others join in.
The steady adoption of Medicaid expansion has occurred even though the ACA, otherwise known as Obamacare, continues to be unpopular among Republicans. Driving the expansion even in Republican-dominated states is the law’s basic structure, which not only makes Medicaid expansion an excellent deal financially but also creates powerful allies in favor of it.
For a major policy reform, Medicaid expansion’s staying power is unusual. Indeed, legislatures in political battlegrounds regularly repeal laws adopted when the other party was in charge. Michigan’s newly Democratic legislature just passed a repeal of a right-to-work law adopted in 2012 by Republican majorities after the last GOP landslide in that state; Republicans will surely re-reverse it the next time they win big in state elections. In Minnesota, a new Democratic majority is passing a series of voting laws reversing what Republicans did on that subject when they had the chance.
But Republican victories giving them control of statehouses over the last decade haven’t produced a single repeal of Medicaid expansion; in fact, GOP lawmakers rarely even try, given the damage it would do to state finances.
That means that for the 10 states still resisting the expansion, they just need one moment when circumstances favoring passage overwhelm the basic Republican opposition to the program — and then they will have it for good.
Several factors, some created by the terms of the Affordable Care Act and some that are just part of the regular rhythms of politics, have made it more palatable for Republican states to adopt the expansion.
First, the ACA is helpful to hospitals in less affluent rural communities, which often are Republican-leaning areas. And hospitals are the big institutional losers under the ACA when a large number of their patients remain uninsured. Hospitals are exactly the kind of organized interest, with clear goals and the ability to work together, that the U.S. political system tends to reward.
Expanded Medicaid remains a great deal for state budgets, since the federal government covers almost all the costs. Right now most states have healthy budget situations, but when they don’t? It’s going to be hard for them to say no to an easy fix.
Passage in some states also creates a strong self-interest among the holdouts to drop their opposition. Turning down federal funds means that taxpayers from the 10 holdout states are subsidizing health care for people in California, New York and the other expansion states. That’s a pretty good argument for those favoring expansion. (2)
Another boost for expansion is that governors remain the weakest link in the partisan voting trend. States such as Louisiana and Kansas that vote solidly Republican in presidential races currently have Democratic governors; similarly, Democratic Massachusetts and Maryland until recently had Republican governors. North Carolina’s legislature is run by Republicans, but having a Democratic governor probably made adopting Medicaid expansion a lot easier.
Republicans haven’t changed their minds about Obamacare. But as time goes on their obsession over it will likely fade. Florida’s Ron DeSantis, Texas’ Greg Abbott and other leading Republican governors either emerged during the Tea Party era or were already in office at the time. For the next generation of Republicans, hostility toward the ACA and its namesake might not be as potent.
When enough of these elements are present, even a very Republican state can occasionally have the votes to accept expanded Medicaid. And once that happens, it’s a done deal, no matter the level of partisan animus. Which is how we’ve reached 40 states today, and why 50 seems inevitable.
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(1) Granted, many Republican states got there partially through ballot measures, some of which led to extended battles against implementing what the people had voted for. But eventually, Republican politicians in those states accepted Medicaid expansion, and none of them came close to repeal after implementation.
(2) Ten years ago, opponents could at least say that they were helping undermine the ACA in anticipation of eventual repeal. But after Republicans failed to repeal the Affordable Care Act in the summer of 2017, the national party has pretty much ignored any broad health-care ideas.
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ABOUT THE WRITER
Jonathan Bernstein is a Bloomberg Opinion columnist covering politics and policy. A former professor of political science at the University of Texas at San Antonio and DePauw University, he wrote A Plain Blog About Politics.
This column does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.
