Since the day Donald Trump took office, he and Republicans in Congress have had government health care programs like Medicaid in their sights. And reactions across the country, highlighted by recent special elections in Pennsylvania and Alabama, suggest this is backfiring in a spectacular way. Their policies are so out of line with public thinking that the more they push them, the higher the likelihood that they put the country on an inevitable path to Medicaid, Medicare or some other health care plan that is ubiquitous and available to all.
Take Medicaid. Since Trump’s election, Congress has relentlessly attempted to slash the program, which covers one in five Americans. After failing to cap it and cut its funding by one-fifth over the next decade, Trump again called for cuts in his State of the Union address. The Trump administration has also given states the green light to impose work requirements on Medicaid recipients, which the Center on Budget and Policy Priorities says will result in “less access to care, worse health outcomes, and less financial security.”
So far, three states — Kentucky, Indiana and Arkansas — have won approval for their work requirements and seven more have pending requests with the Trump administration. Nearly 640,000 people would be vulnerable to losing their health coverage if all 10 states go ahead with work requirements.
While these efforts will hurt many families, the real story of the impact of this continued assault has been to significantly increase Medicaid’s popularity and cause Americans in large numbers to press for expanding its availability. According to the latest Kaiser Health Tracking Poll, 84% of Americans now want to continue the Affordable Care Act's Medicaid expansion to people slightly above the poverty line.
For good reason. States that expanded Medicaid have seen their citizens’ health and financial outcomes improve and have helped rural hospitals and the economy, while providing a lifeline for single mothers and helping states combat the opioid epidemic.
Perhaps the most significant response is that in many parts of the country, citizens are turning to local ballot initiatives to deliver the changes they want but aren’t getting from political leaders. In the reliably red states of Utah and Idaho, for example, initiatives to expand Medicaid coverage are making their way to the November ballot. Polling shows the efforts to be highly popular, with support across the political spectrum.
The Utah Decides Health Care Act would expand Medicaid and maintain Children’s Health Insurance Program funding for tens of thousands of vulnerable Utahns. A December poll of registered voters found 59% backed the initiative.
Reclaim Idaho has filed a similar proposal, aiming to close the “Medicaid gap” for 78,000 Idahoans who lack access to affordable health care because they are too poor to qualify for Obamacare subsidies but not poor enough to qualify for Medicaid (which in Idaho means earning just $24,000). While elected officials in Idaho have failed to address the issue, a poll late last year showed 76% of Idahoans favor expanding Medicaid.
And last month, in Nebraska, a coalition of local organizations and political leaders announced that they too are filing an initiative for the November ballot to expand Medicaid in the state and bring health care to some 90,000 people.
Momentum is growing elsewhere. Groups in Montana are taking steps to add a Medicaid expansion initiative to the state ballot this November, with the aim of making the expansion permanent instead of allowing it to sunset as scheduled next year. And the Fairness Project is in early talks with several states about ballot initiatives in 2020.
If there is any doubt that ballot initiatives can bring major change where elected officials fail, look back just a few months to November when Maine voters, by nearly 18 percentage points, used a ballot measure to bring Medicaid coverage to 70,000. Prior to the vote, Maine Gov. Paul LePage had vetoed expansion five times.
All this momentum shows that when under threat, Americans act not just to protect their rights, but go further.
This Pac-man politics, where the chased become the chasers, was on vivid display six years ago when states like Washington, Maryland and Maine, after being besieged by efforts to outlaw marriage between same sex couples, used the ballot to ensure its legality. Along with a number of other efforts, this ultimately led to the Supreme Court decision to make same-sex marriage legal across the country.
We may be at the beginning of a similar cycle now in health care. Trump and Congress have Americans concerned that their access to care is at risk to the point where many are taking action. The response isn’t ending with the defeat of repeal, and may not stop until health care is expanded to all Americans.
By Andy Slavitt and Jonathan Schleifer