Ride or die.
Support The Bulwark.
  Join Now

Medicaid will Shape the 2020 Election. Are Republicans Ready?

November 12, 2019
Featured Image
LAKEWOOD, CO - AUGUST 21: A terminally ill patient sits in the sun at the Hospice of Saint John on August 21, 2009 in Lakewood, Colorado. The non-profit hospice, which serves on average 200 people at a time, is the second oldest hospice in the United States. The hospice accepts patients, regardless of their ability to pay, although most are covered by Medicare or Medicaid. (Photo by John Moore/Getty Images)

Last week, former Obama health care official Andy Slavitt called health care the “kryptonite to beat President Donald Trump” in a Washington Post op-ed. Newly elected Kentucky Governor Andy Beshear, a Democrat in a blood-red state, used the Republican attacks on some provisions of Medicaid as the major issue in his upset win. Beshear said health care is a “basic human right and our administration will treat it as such” and beat the Republican incumbent.

The issue extends beyond Kentucky. In an extensive poll released last week by the Kaiser Family Foundation and Cook Political Report on voter opinion in four key Midwest swing states (Minnesota, Michigan, Pennsylvania, and Wisconsin), respondents rated health care as one of the only issues in which President Trump’s approval rating (-21) is lower than his overall job approval (-18).

“These are tough numbers [for Trump] if the Democrats can capitalize on them,” political analyst Charlie Cook said of the poll in a TV interview. What was perhaps most telling in Cook’s poll was that the number of voters in those four states who listed health care as their top priority (20-22 percent), lined up almost identically with the percentage of those who identified themselves as undecided independents (21-25 percent).

How this will play out in the general election a year from now is, of course, tough to call at this point. It all depends on whom the Democrats nominate, whether they place health care above climate change in their hierarchy of issues, and whether Trump’s impeachment proceedings have any long-term traction with voters.

The Democrats might be foolish enough to push for the pipe dream of “Medicare for all” instead of focusing on the narrative that Trump is trying to eliminate programs that most voters like and support. There is still a lot of uncertainty this far out.

But in the end, the public tends to vote with its pocketbook, and in these key states in the Midwest—swing states crucial to determining who the president will be—the voters seem less interested in “quid pro quo” and more concerned for “keep my health care and save my dough.”

One of the specific areas where the fight over changes in health care is coming into play politically, has to do with the expansion of the Medicaid program, primarily because the original Affordable Care Act had a “coverage gap” for people who had “incomes above Medicaid eligibility limits but below the lower limit for Marketplace premium tax credits.” The solution was to raise the eligibility limit to 138 percent of the poverty level.

To date, 36 states (plus Washington, D.C.) have adopted the Medicaid expansion. The Medicaid enrollment in expansion states has increased by about 13.1 million since those state adoptions started in 2013. While the haves- and have-nots of Medicaid expansion do not fall entirely into red state/blue state designations, most of the states that have adopted the expansion are blue, and most that have not are red.

A lawsuit filed by 20 states regarding the constitutionality of funding provisions of the Affordable Care Act is pending in federal court—a lawsuit, again, filed by mostly red states without the expansion—could upset the apple cart completely. Meanwhile, before the court rules, the Trump administration has moved to allow some states to change how they administer their Medicaid programs. Some of these changes involve lowering funding, resulting in restrictions of services covered, some involve a work requirement for able-bodied adults.

Medicaid as a Factor in the Kentucky Politics
It was that work requirement that came into play in the Kentucky governor’s race. In the week before the election, incumbent Republican governor Matt Bevin asked some simple questions about Medicaid qualifying rules:

Is there anyone in this room that thinks it is a good idea for able-bodied, working-age men and women between the ages of 19 and 64 who have no dependents—and they’re able-bodied, they’re healthy—and they choose not to work? . . . How many of you think it’s a good idea for you to subsidize them and allow them not to work? Anybody?

Many observers thought that asking such questions in a state that voted for Trump by 30 points was a reasonable, even wise. But Kentucky is one of the expansion states, with 1.2 million people on Medicaid—a whopping 27 percent of the state’s total population, including about 479,000 people who came on board because of the expansion.

We cannot be certain that Governor Bevin’s attempted Medicaid reform was the primary deal-breaker for Kentucky voters. He had a tumultuous history on a variety of issues. But one poll holds a clue suggesting that the work requirement could at least have been a factor. A poll conducted in late 2018 (although released only in September) found that 54 percent of Kentuckians enrolled in Medicaid who might have been affected by the possibility of a work requirement had heard about it. Presumably that percentage rose considerably as the work requirement became a prominent issue in the gubernatorial race. In particular, the issue appears to have had a big impact on voters in low-income, rural areas. Of the top ten counties nationally with the highest percentage of residents on Medicaid (45-50 percent), nine of them are in Kentucky. Those nine counties voted for Trump in 2016 by astounding margins: between 70 and 89 percent. But in the governor’s race last week, Beshear won three of those counties outright, and all of them saw big drops between the totals Trump received and what Bevin got. For example, in Knott County (population 15,000), Trump won with 82 percent of the vote while Bevin lost with 49 percent.

A 33 percent drop because of Medicaid? Maybe.

Medicaid Politics Beyond Kentucky
A question that remains unanswered is whether these health care issues that mattered in very conservative Kentucky will also matter in the presidential race. One reason it’s hard to know is that hard-core liberals and entrenched conservatives view Medicaid differently. Liberals see Medicaid more as a human right for the poor, while conservatives see it more as an overused entitlement.

But on the purely practical basis of how average Americans see Medicaid in 2019, it is clear now there has been a change in the public’s view. A poll by the Kaiser Family Foundation released this summer showed that 85 percent of Democrats, 76 percent of independents, and 65 percent of Republicans had a “favorable” view of Medicaid. In an earlier version of the same poll, released in January, 75 percent of the respondents, instead of seeing Medicaid as a government handout that should be scaled back, actually favored expanding Medicaid as an option for anyone who doesn’t get health insurance at work.

In 1990, about 9 percent of the national population was on Medicaid. That number has now jumped to about 23 percent. High Medicaid participation rates in California and New York skew that number upward, but the figures are also fairly high in the four states studied by the Cook Political Report: Michigan (22.7 percent); Pennsylvania (22.9 percent), Minnesota (18.4 percent), and Wisconsin (17.7 percent).

That is about 7 million Medicaid-enrollee adults in those four states seen as key to Trump staying in office. Wisconsin is not one of the expansion states, but the three others are, and they have a large number of those Medicaid expansion participants: About 1.7 million adults in Minnesota, Pennsylvania, and Michigan have joined up with Medicaid since the “coverage gap” enrollment came into being.

How important are the states in the Cook survey to Trump’s re-election? In all of those states, the 2016 election results were very tight. Trump won Michigan, Pennsylvania, and Wisconsin—with their 46 combined electoral votes—by a total of just 77,000 votes. Now consider that just those three states have more than 6.4 million people on Medicaid. And about 1.5 million of those are on Medicaid because of the ACA.

When you drill down further, it becomes even clearer that Medicaid is a local issue that could swing national results. Erie County in Pennsylvania has had economic issues because of industrial job loss, and 28 percent of its residents are now on Medicaid (76,000). About 20 percent of the 1.2 million residents of Allegheny County (where Pittsburgh is) are on Medicaid, and about 60,000 of them were added through the expansion program.

Macomb County in Michigan, which flipped from Democratic to Republican in 2016, has close to 200,000 people (22 percent of the county) on Medicaid, and about 58,000 were added with the expansion. Macomb County is an example of how Medicaid is no longer just an urban core program; the suburbs—where Trump’s popularity is declining—have growing numbers of Medicaid recipients.

Plus, many institutions, businesses, and doctors involved in health care like the Medicaid expansion, because it has moved patients from the unpaid and expensive emergency-room care side of the ledger to paid preventative care at doctors’ office visits. That’s part of the reason why the Republican business community in Medicaid expansion states isn’t so keen on bashing it.

The problem for the Trump 2020 campaign is simple to define but very difficult to address. On the one hand, attacking an entitlement like Medicaid appeals to the Trump faithful in a very clear way. On the other hand, such attacks can alienate the middle-ground independent voters Trump won in 2016 and desperately needs this time as well.

In other words, will Trump push a Medicaid work requirement that would please voters in Oklahoma and Mississippi (states he is already assured of) if doing so might cause him to lose voters in Michigan and Pennsylvania (states he desperately needs)?

The logical thing for Republicans to do is to push off the table—until after the election—the ACA repeal and Medicaid changes, like the work requirement. But are Trump and his minions capable of reeling all this in and keeping their mouths shut on an issue that might hurt more than help?

One of the most elementary but important determining factors in political campaigning is that satisfying the desires of certain supporters can sometimes have negative consequences overall. We’ll see if Trump understands that.

Daniel McGraw

Daniel McGraw is a freelance writer and author in Lakewood, Ohio. Follow him on Twitter @danmcgraw1.