Universal Health Care Is a Pro-Democracy Policy

Just what the doctor (of political science) ordered. Photo: Scott Olson/Getty Images

Increasing voter turnout is hard. Robustly progressive, anti-Establishment campaign messages rarely do the trick. Well-funded registration campaigns targeted at nonvoting communities have barely made a dent. Even implementing policies that make it easier to vote — whether by increasing opportunities to register or expanding early voting — have not generally correlated with higher rates of civic participation.

But giving low-income people health care has.

By refusing to implement the Affordable Care Act’s Medicaid expansion, Republican-controlled states have likely condemned tens of thousands of Americans to premature deaths. But the GOP’s sociopathic decision to prioritize symbolic anti-Obamaism over the material interests of its constituents has also had one beneficent consequence: It provided researchers with a nifty natural experiment for assessing the impacts of expanding access to public health insurance. For example, by examining changes in private market premiums in the border counties of Medicaid-expansion states and comparing them with their neighboring counties in holdout states, analysts have shown Medicaid expansion reduces premium costs for non-beneficiaries. Meanwhile, other studies have shown that Medicaid expansion is associated with higher levels of self-reported health and financial well-being, as well as financing for rural hospitals.

Border-county studies have also yielded a less intuitive benefit of expansion. A 2018 study from the political scientists Joshua Clinton and Michael Sances found that in counties with high populations of Medicaid-expansion-eligible residents, the policy’s implementation increased both voter turnout and registration in the 2014 midterm elections. A 2017 study from Missouri political scientist Jake Haselswerdt found a similar correlation between Medicaid expansion and higher rates of voter turnout at the congressional district level in the 2012 election. Finally, just this year, a study of Oregon’s experiment with expanding Medicaid by lottery (prior to the Affordable Care Act’s passage) found that the program increased its recipients’ individual likelihood of voting by 2.5 percentage points.

Data for Progress helpfully draws out the implications of these findings in a recent report. Using Medicaid’s average impact on turnout across the three studies and the Kaiser Family Foundation’s estimates of the Medicaid coverage gap in the 13 states that still haven’t implemented expansion, the progressive think tank calculates that full implementation of Medicaid expansion would bring as many as 1.3 million Americans off our democracy’s sidelines and into the electorate by 2022.

Photo: Data for Progress

Precisely why Medicaid expansion has reliably increased voter participation is not entirely clear. But three factors are likely relevant: One, when registering for Medicaid, nonvoters also have the opportunity to register to vote. Two, by improving recipients’ physical and financial well-being, the program may give some nonvoters greater capacity to participate in civic life. Finally, and perhaps most hopefully, by providing nonvoters with a valuable government service that makes a tangible difference in their lives, Medicaid expansion may give them a clearer stake in the political process than they previously had. This would be consistent with MIT political scientist Andrea L. Campbell’s research on the development of Social Security, which suggests the program was a cause of American seniors’ high levels of voter participation, not a mere response to that participation. Which is to say, older voters did not cast ballots at such elevated rates until Social Security alerted them to the stakes of partisan conflict.

To the extent that this basic story holds up, it would ostensibly apply just as powerfully to the establishment of truly universal public health insurance. As of yet, there’s little evidence that the mere idea of Medicare for All, as a campaign promise, can mobilize large numbers of nonvoters. But once implemented, universal coverage appears likely to improve the health of our body politic.

Universal Health Care Is a Pro-Democracy Policy