These days, progressives spend a lot of time arguing online about exactly how we should overhaul the American health-care system once we’ve defeated Donald Trump, evicted Mitch McConnell’s majority, and converted Joe Manchin to the gospel of Eugene Debs — which, much of the time, is quite worthwhile! Our nation’s approach to medical provision is a humanitarian and economic travesty that grows more onerous and unaffordable by the day. And while some of its worst symptoms can be mitigated at the state level, eradicating the system’s underlying sickness will require federal action.
But at some point in the next 24 hours, liberals and leftists should probably take a quick time-out from debating the relative merits of a head tax versus a mandatory “income-based premium” and make sure they don’t have any friends in Virginia, Kentucky, or Mississippi who could use a reminder to vote tomorrow. Medicare for All won’t be on the ballot for at least a year, but on Tuesday, voters in those three states just might win “Medicaid for more.”
As you may be aware, the Affordable Care Act made state governments an offer they ostensibly couldn’t refuse: Expand your Medicaid programs to households earning up to 133 percent of the federal poverty level and Uncle Sam will cover 90 percent of the costs; refuse to expand Medicaid and he’ll cut off federal funding to your existing Medicaid program. But then, John Roberts’s Supreme Legislature decided to rewrite the bill. For extremely dubious constitutional reasons, the high court found Congress could not condition existing Medicaid funds on states expanding their programs. This still left GOP-controlled states with strong incentives for expanding Medicaid: Doing so would not merely aid their most vulnerable constituents but also enrich their state’s hospitals and inject millions of dollars into their broader economies. But in many states, Republicans decided that when the goals of hurting the poor and serving the business community come into conflict, immiserating the indigent takes precedence.
One of the holdouts is Mississippi. Few places in the country would benefit more from Medicaid expansion than the Magnolia State, which has the fifth-highest uninsured rate — and 50th-highest median income — in the USA. The state GOP’s intransigent refusal to accept desperately needed federal largesse is one reason a Democrat has a genuine chance to win a gubernatorial election in the Deep South tomorrow. The other is that the party’s nominee is the state’s longtime attorney general, Jim Hood. Polling of the race has been limited. And the task of accurately gauging the state of the contest is complicated by the fact that Mississippi maintains a Jim Crow–era election system that requires candidates for statewide office to win both the popular vote and a majority of the state’s congressional districts (a rule that, when combined with gerrymandering, prevents gubernatorial candidates from winning elections on the strength of landslide support among African-Americans). If neither candidate hits both of those thresholds, the Republican-dominated state legislature will appoint its preferred governor. Nevertheless, existing surveys show a surprisingly tight race, at least in the statewide vote. And if Hood does manage to pull off the upset, it’s conceivable that the Republican legislature will heed its constituents’ message (and economic interests) and allow for at least a partial expansion of public health insurance to the poor.
Kentucky, meanwhile, was one of the first red states to expand Medicaid, thanks to former Democratic governor Steve Beshear. But after Republican Matt Bevin replaced Beshear in the governor’s mansion, he secured permission from the Trump administration to impose strict work requirements on the program. There is no evidence that such requirements “work” on their own morally odious terms. Denying unemployed people medical care does not make them more likely to work; it just reduces the number of low-income people who sign up for Medicaid, which seems to be the point. Anyhow, Bevin’s work requirements are currently on hold pending the result of a legal challenge. But there’s a good chance the courts will eventually give him the green light — if he wins reelection tomorrow. Which is no sure thing: His opponent, Kentucky’s attorney general (and Steve Beshear’s son), Andy Beshear, is narrowly ahead in some recent polls. Should he prevail, those work requirements can be nipped in the bud.
In Virginia, Democrats already have control of the governor’s mansion (thanks to the American Justin Trudeau), but Republicans have held on to narrow majorities in the state’s Senate and House of Delegates. And they’ve used that grip on power to, among other things, force some eligibility requirements onto the state’s Medicaid expansion. If Democrats can flip two seats in each chamber tomorrow, they’ll have the power to scrap those requirements — and, just maybe, to pursue farther-reaching expansions of public health insurance.
Once tomorrow’s elections are in the books, progressives won’t have to wait long for their next opportunity to advance the cause of health-care justice. On November 16, Louisiana’s Democratic governor John Bel Edwards will be up for reelection. His victory would entrench the state’s fragile expansion of Medicaid; his defeat would likely result in effective cuts to the program.
Winning incremental expansions in public-health-insurance provision in these states won’t fix our nation’s broken health-care system or strike a fatal blow to neoliberalism. But it would probably keep many hundreds of human beings on this planet — and in the lives of those who love them — for years longer than would otherwise be the case. According to a recent working paper from the National Bureau of Economic Research, the failure to fully expand Medicaid has condemned roughly 15,600 Americans between the ages of 55 and 64 to premature death each year. We can save a lot of them, even before the revolution.