For the second time in two weeks, Oklahomans have made President Donald Trump look bad. First there was the sparsely attended Tulsa rally. Now Sooner State voters have opted to expand Medicaid under the Affordable Care Act.
There’s an immediate, narrow problem for the White House, and a broader, more strategic one. In the short term, the very tight “yes” vote imperils a plan to turn Medicaid funding into a block grant from the federal government to states, using Oklahoma as a pilot.
In a deeper sense, though, the vote is a warning sign for Trump, because it shows how he’s at odds with even many conservative voters on health care. Last week, the Trump administration asked the Supreme Court (again) to throw out the Affordable Care Act. Meanwhile, voters in a state so red that the president chose it for his big comeback rally have voted to adopt an expansion of coverage under the law—the fifth time voters in a Republican-governed state have done so, and the fourth in the past two years.
It’s not entirely shocking that amid a pandemic and a massive unemployment crisis, voters would rather have more health coverage than less. And while Obamacare remains unpopular among conservative voters—three-quarters of Republicans had an unfavorable view of the law in the Kaiser Family Foundation’s most recent tracking poll—the actual components of the law, especially requiring insurers to cover people with preexisting conditions, have always been popular.
Moreover, the ACA has always been most popular when it is under attack. The law has been more popular than not, according to the KFF poll, since about the time that Trump took office, promising to dismantle the law. Trump attempted repeatedly (though clumsily and distractedly) to repeal Obamacare in the first year of his administration, aiming to complete a long-standing GOP campaign pledge. But neither Trump nor other Republicans ever developed a replacement plan that achieved the conditions of being cheaper and providing greater coverage, which Trump had laid out, and the repeal push was hamstrung by Trump’s own inconstant attention to the legislative process, and ultimately by Senator John McCain.
The result was a remarkable political inversion: Though the ACA was a millstone around the Democratic Party’s neck in the 2010 and 2014 elections, especially, the party used it to great effect in 2018, when Democrats took back the House, using health care as a central campaign theme. Some Democrats had argued it should be the party’s main theme in 2020 (though there are sharp divides within the party about what the best health message is), and worried that the party was straying too far away from its bread and butter.
But the pandemic has put health back on the agenda, as has Trump’s plea to the Supreme Court. The administration filed a last-minute brief agreeing with a challenge to the law, which says that because the law’s mandate that individuals hold insurance was struck down—also at the White House’s urging—the whole law should be. The decision divided Republicans, with some strategists and officials seeing it as a self-defeating move.
The vote in Oklahoma shows why. “Obamacare repeal” as a concept may still be popular with some core Republican voters, but it’s not as potent as it was before the pandemic—and besides, the coverage itself is popular. Sooner State voters effectively circumvented the will of Republican Governor Kevin Stitt, who had sought a more limited expansion. That’s in keeping with a pattern: When voters in GOP-led states have gotten the chance to vote on Medicaid expansion, they’ve tended to favor it. In other cases, Republican governors and lawmakers have sensed the political wind and moved forward themselves.
The idea of Medicaid expansion is itself a creation of Republican court challenges to the law. The ACA expanded the eligibility for Medicaid, the Great Society–era program, to Americans making as much as 133 percent of the federal poverty rate. But the Supreme Court ruled in 2012 that the federal government couldn’t coerce states into accepting the expansion—instead, states could opt in or out. Predictably, more liberal states opted in, while more conservative ones did not. Also predictably, states that opted in tended to have better health outcomes. While Republican politicians oppose Medicaid expansion for reasons of ideology and fiscal conservatism, it’s not shocking that rank-and-file voters in their states are eager to get better coverage and federal dollars.
In a sense, Trump has fallen into a trap of his own making. He grasped that entitlements were popular among Republican voters in his 2016 campaign, and while other GOP candidates trotted out the usual talking points about social spending, Trump promised to protect Social Security and Medicare. In office, however, he has waffled, proposing budgets that cut entitlements programs, though the budgets have not been enacted. Having tapped into the latent popularity of social spending among Republican voters, he now risks their anger if he reverses course.
Medicaid, which is aimed at the poor, has not always been as popular as Social Security and Medicare, both of which are aimed at older Americans. The latter two have been viewed as “earned” entitlements, while Medicaid has sometimes been viewed as a welfare program, with the same negative racial connotations that other welfare programs carry. So it’s notable that Oklahoma voters joined their fellow citizens in Idaho, Nebraska, and Utah (2018) and Maine (2017) in supporting a Medicaid expansion.
Oklahoma is not the final test this year. In August, Missouri voters will also vote on Medicaid expansion. There, too, Republican Governor Mike Parson opposes the expansion. In a sign of the way that Obamacare has gone from a salubrious wedge issue for Republicans to a pain point, Parsons moved the referendum from the November ballot to an August primary.
Even if Missouri votes down the expansion, the results in Oklahoma and elsewhere make the overall trend clear. As Donald Trump recognized in 2016, and as the 2018 election reinforced, entitlements are popular with voters. By flouting that popularity and trying to sink Obamacare a few months before the election, he risks a painful reminder of the lesson he once taught.