Just after the Affordable Care Act fully took effect in 2014, around two dozen GOP-run states were refusing to implement the ACA’s expansion of Medicaid. This left millions of Americans languishing in a needless crisis, all because ACA-despising Republican legislators were turning away enormous sums of federal cash earmarked to cover their state’s poorest adult residents.
But in the near-decade since, health-care advocates have painstakingly overcome that opposition, and many of those states have now embraced the expansion. Between this and the failure of years of ACA repeal drives, the GOP has essentially been routed in the Obamacare wars.
The scale of this defeat is evident in big news out of North Carolina, where leaders in the GOP-controlled legislature announced a deal Thursday to accept the expansion. It will require hospitals to pay the state’s minimal contribution to the cost. (The federal government generally funds 90 percent.)
Republicans accepted this deal only after years of ferocious resistance. And this is a tremendous win for advocates and Democrats, because it stands to cover as many as 600,000 poor North Carolinians, in a state that proponents have targeted for years.
The popularity of Medicaid appears to have surprised conservatives, who apparently saw it as an easily targeted big-government program for poor people. The prospect of cuts to Medicare — whose beneficiaries are vocal, organized seniors — presented a well-understood danger. But surely Medicaid cuts wouldn’t matter as much politically.
Reality has shown otherwise. In the past dozen years or so, voters in seven GOP-run or red-leaning holdout states have defied Republican legislatures by voting in referendums to accept the expansion. In a number of others, Republican officials have initiated acceptance through executive actions or legislation. If North Carolina’s legislature passes the new deal, only 10 holdout states will remain.
What’s more, when congressional Republicans tried to repeal the ACA in 2017, which would have taken Medicaid coverage from millions more Americans, they faced an unexpectedly furious public backlash and backed down despite controlling all of Washington.
Today, a remarkable 91.7 million Americans are on Medicaid and its children’s subsidiary, CHIP — more than a quarter of the country’s population. Republicans can’t ignore that any longer.
All of this is creating a strange divide in the GOP between state and national lawmakers.
On the state level, it’s becoming clearer that resisting the expansion is politically untenable, particularly in purplish states. In North Carolina, for instance, the expansion has had overwhelming public support. When the state Senate leader finally accepted the expansion in principle last year, he openly admitted he had fought it long and hard before capitulating to its fundamental financial logic.
“Most red states have come around to the view that the federal money on the table for their low-income residents is too hard to turn your back on,” Larry Levitt, the Kaiser Family Foundation’s executive vice president for health policy, tells us.
Yet back in Washington, congressional Republicans are still looking to cut Medicaid. Some are mulling a plan to cut $2 trillion from Medicaid. And a bloc of 173 House conservatives has proposed to convert Medicaid and CHIP to block grants and reduce their funding by $3.6 trillion over 10 years.
But if an anti-Medicaid stance is becoming untenable in even somewhat red-leaning places — such as North Carolina — it seems likely to hurt broader GOP prospects as a national party position.
Consider what could happen in 2024. As USA Today columnist Jill Lawrence details, most of the main GOP presidential contenders, including Florida Gov. Ron DeSantis and former South Carolina governor Nikki Haley, either opposed the expansion in their states or fought for ACA repeal.
The eventual GOP nominee will surely want to keep the debate over the ACA as abstract as possible. He or she will likely rail that “Obamacare” represents Big Bad Government in some undefined sense while vaguely committing to repeal to keep the base and conservative thought leaders happy.
But the Medicaid expansion in places such as North Carolina will make the stakes a lot more concrete. The repeal vow will threaten the coverage of hundreds of thousands in that state. The expansion would deliver a big lift to struggling rural hospitals there, as it has in other expansion states. These gains will also be threatened.
All of that won’t be easy for the GOP nominee to navigate in a state that Republicans have been winning lately, but only by very slim margins.
True, the battle is far from entirely won. Enormous populations of Medicaid-eligible uninsured people still remain in big GOP-controlled states such as Florida, Texas and Georgia, with no hope of an expansion anytime soon.
But now, if North Carolina’s expansion goes through, only a fraction of the original holdout states will remain, most with relatively small populations. If you had predicted all this a decade ago, it would have seemed impossibly optimistic and naive.