When left-wing Democrats push for universal benefits and expansive new policies, they do so with a theory of politics in mind. It goes like this: The reason to fight for debt-free college or Medicare for all isn’t just to improve life for Americans, but to build new ground for progressive political activity. New programs create new constituencies, and new programs with broad benefits can give more Americans a stake in the expansion and preservation of the welfare state. Conservatives know this. That’s why they’ve fought so hard to block or undermine even modest new programs.
Take the Medicaid expansion under the Affordable Care Act, which stands as the latest proof of the truth of that progressive theory.
In its original form, the expansion relied on a significant bit of legislative coercion. If states adopted it — and expanded Medicaid eligibility to up to 138 percent of the federal poverty line for virtually every adult — the federal government would bear 100 percent of the cost for the first three years, phasing down to 90 percent of the cost over time. But if states refused, they wouldn’t just lose this new funding — they would lose all existing federal Medicaid funds.
It was an offer states couldn’t refuse, which — for Chief Justice John Roberts — made it unconstitutional. In his opinion for the majority in NFIB v. Sebelius, he invalidated the penalty. States could refuse the expansion without losing all Medicaid funding. A program intended to expand health insurance in every state was now voluntary.
By the time President Barack Obama left office in January 2017, 32 states and the District of Columbia had expanded Medicaid under the Affordable Care Act. The holdouts were states where Republicans held enough power to either reject the expansion or keep a Democratic governor from implementing the program. Future prospects looked poor. During the 2016 presidential campaign, Donald Trump had promised to repeal Obamacare. With Republican majorities in the House and Senate, the incoming president was poised to do just that.
But his plans unraveled. The legislative effort to torch Obamacare ended in failure, sunk by key Republican defections (John McCain voted no in a critical, late night vote) and an intense, nationwide public outcry centering on the Medicaid expansion. In Kentucky, where in 2014 the state’s Democratic governor Steve Beshear expanded Medicaid, voters turned out to defend the program, protesting against the Senate majority leader, Mitch McConnell, and other Republican lawmakers. Republican lawmakers faced similar protests in Pennsylvania and West Virginia, as well as at the Capitol itself.
Medicaid also fueled an offensive drive. In 2015, Louisiana Democrats ran on Medicaid and won the governor’s mansion. In 2017, Virginia Democrats placed the Medicaid expansion at the center of their campaign and swept the ballot, winning every statewide office and fighting Republicans to a literal tie in the state legislature.
Maine voters approved the Medicaid expansion in a 2017 ballot initiative, but the Republican governor, Paul LePage, refused to implement it. In her 2018 campaign to succeed LePage, the Democratic candidate, Lisa Mills, pledged to implement the expansion on her first day in office. She won and immediately followed through. And last year, the fight to protect or expand Medicaid drove Democratic victories in Louisiana (where incumbent governor John Bel Edwards won re-election), Kentucky (where the Democratic candidate Andy Beshear unseated the incumbent Republican governor, Matt Bevin) and Virginia (where Democrats won a majority in the state legislature for the first time since 1993).
Medicaid also helped Kansas Democrats win a 2018 election for governor, and on Thursday the state’s Democratic governor, Laura Kelly, and its Republican State Senate leader, Jim Denning, announced the details of their compromise to expand the program. The state will implement the expansion, covering up to 150,000 additional Kansans. In return, Republicans will get a pilot program meant to reduce private health insurance premiums and keep people from dropping existing insurance and signing up for Medicaid, paid for an increase in the state cigarette tax by a $1 per pack. The proposal would also allow the state to charge recipients a premium of up to $25 per individual and $100 per family. If and when it becomes law, Kansas will become the 37th state to expand its Medicaid program.
Major new programs are difficult to pass. The struggle to make them happen is almost always “divisive.” But if you fight that fight and win, then in addition to passing the program, you’ve also laid groundwork for future political victories. Despite being undermined by the Supreme Court, the Medicaid expansion has found a toehold in American politics, producing a powerful constituency for itself.
The social safety net depends on public support to survive. And one way to generate that support is to make it as strong and expansive as possible, with the most ambitious policies you can bring to fruition. Conservatives understand this in their bones. As Democrats debate their choices and decide on a presidential nominee, they should also keep this lesson uppermost in their minds.
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