In the ACA, former President Barack Obama significantly expanded Medicaid by allowing states to extend eligibility to more low-income, uninsured adults; about 11 million of the 20 million people who gained coverage under Obamacare did so through Medicaid. After the GOP regained the House majority in 2010, it responded by repeatedly passing legislation to undo the expansion and sharply reduce the underlying program itself. But those proposals were blocked either by the Senate or by Obama.
Following those well-worn tracks, this year’s House GOP health bill proposed to eliminate the ACA’s Medicaid expansion and to limit federal payments to states for the underlying program. The combined effect would have slashed federal Medicaid spending by $880 billion over the next decade and eliminated coverage for 14 million people, the Congressional Budget Office calculated. As Trump noted in his Wednesday interview with Fox Business Network, Republicans are counting on those spending reductions to help fund the tax cuts up next on their priority list.
But the Medicaid cutbacks have provoked unanticipated resistance from centrist House Republicans, particularly from states that had expanded eligibility under the ACA. Republican senators from West Virginia, Alaska, Arkansas, Ohio, and Nevada— all expansion states—also questioned the cuts. GOP governors from those last three states, plus Michigan, added their own warnings. None of this guarantees that Republicans won’t eventually coalesce around a plan to repeal Obamacare and squeeze Medicaid. But clearly the program’s politics have grown more complicated for the party.
What’s changed? One factor is that the ACA’s Medicaid expansion has provided clear benefits to providers and patients alike. In states that expanded Medicaid, hospitals are providing much less uncompensated care, which means fewer costs they must shift to paying customers. Rural hospitals have particularly benefited from expansion “because people there have less income and less access to other forms of coverage,” noted Edwin Park, vice president for health policy at the Center on Budget and Policy Priorities, a left-leaning research group.
Working-age adults also report much higher levels of financial and medical well-being in expansion states. A 2016 study by the Commonwealth Fund, a nonpartisan health-research organization, found that far fewer adults reported not seeking attention for a health problem—or problems paying their medical bills—in New York and California, which expanded Medicaid, than in Texas or Florida, which did not.
Even more important than the Medicaid expansion’s benefits may be its beneficiaries. By expanding eligibility, Obama brought into the program millions of low-income working adults, many of them older. That shift has occurred precisely as Republicans have grown more reliant on working-class and older white voters. Obama expanded Medicaid’s reach up the income ladder exactly as the GOP electoral coalition extended further down the ladder. Where the two lines cross, congressional Republicans found that their familiar drive to shrink Medicaid suddenly threatened their own voters.