Perhaps more than any other state, Virginia is a microcosm of the national debate over the ACA and its Medicaid expansion over the past six years. After the Supreme Court’s NFIB v. Sebelius decision in 2012 made the expansion optional for states, Virginia became part of the firewall of 25 Republican-led and swing states that initially refused to change their Medicaid programs, which traditionally covered only a small subset of low-income families and people with disabilities.
In early 2013, Republican Governor Bob McDonnell officially decided against expanding Virginia’s program, and like many other Republican governors, leaned on budgetary reasons for his rejection. In a plan designed to outmaneuver local Democrats, the state GOP’s approved budget didn’t cut off future possibilities of expansion, but made any such move contingent upon the implementation of “real, sustainable cost-saving reforms … at the state and federal level,” as McDonnell put it.
But the firewall soon lost some of its strength. Facing both mounting health problems, like the opioid epidemic, and shifting public opinion, the first states to switch sides did so quickly. Michigan, Pennsylvania, New Hampshire, and Indiana launched pitched battles over the program, with mainstream Republicans, Tea Partiers, and Democrats fighting a three-way struggle over different iterations of reform. Michigan’s Republican governor, Rick Snyder, yielded in late 2013. In 2014, New Hampshire’s Republican-led Senate yielded to a Democratic compromise on expanding Medicaid. Later that year, Pennsylvania’s Tom Corbett became the ninth party governor to defect. Many of these Republican crossovers were enabled by special Medicaid waivers that allowed conservatives to constrain program benefits and spending. As governor, Indiana’s Mike Pence helped popularize that approach, crafting his state waiver in 2015 with the aid of then-health-care consultant Seema Verma, who’s now the administrator of the Centers for Medicare and Medicaid Services.
Alaska, Montana, and Louisiana were next to fall, with each facing serious health-care access problems in poor rural areas that Medicaid expansion became a critical tool in fixing. While the GOP’s focus on repealing Obamacare in 2016, as well as the party’s resulting attempts at repeal throughout 2017, chilled some legislative conversations on expansion at the state level, by then the tide was already turning.
Perhaps even because of the GOP promises to repeal Obamacare—which long predated the last round of elections—public opinion on the health-reform program has steadily improved over the years, and Republican recalcitrance has softened. Additionally, Democrats in some swing states and congressional districts have harnessed increasing racial and ethnic diversity, combined with surges in grassroots support, to challenge the GOP’s dominance.