Even in the Deep South, Republicans Are Starting To Come Around on Obamacare
To see how powerful the healthcare issue has become, look to the heart of the Old Confederacy.
This week, I could have written about campus protests, or Donald Trump's courtroom drama, or President Biden's relationship with the Washington press corps. Everyone else is. But out of the headlines, the issue of healthcare keeps demonstrating its power to move American voters. So that's where I'm directing this week's spotlight.
To see how powerful the healthcare issue has become, look to the heart of the Old Confederacy. Mississippi is considering whether to embrace Obamacare.
Yes, that Mississippi, which yields to no state in its opposition to big government.
That Mississippi, which hasn’t backed a Democratic presidential candidate in nearly half a century.
That Mississippi, which delivered landslide victories for Trump in both 2016 and 2020.
Both chambers of the State Legislature have now passed different paths to expanding its Medicaid program under Obamacare, the federal initiative conservatives have loved to loathe for a generation. A compromise melding the two plans is now pending in the legislative session's final days.
Even at a moment of maximum political polarization, some causes remain powerful enough to overcome barriers of partisanship and ideology. The desire for health insurance, as the resilience of the Affordable Care Act shows, is one of them.
From Hyperbolic Warnings to Popular Demand
The history of modern debates over healthcare policy has followed a familiar pattern. Beginning with Harry Truman after World War II, Democrats have proposed offering government healthcare benefits. Republicans, as the pro-business champions of low taxes and minimalist government, have fiercely resisted with warnings of ruinous “socialized medicine.”
In the early 1960s, for example, rising Republican star Ronald Reagan predicted that proposals for an old-age health insurance program would usher in government control of every corner of American life. “We are going to spend our sunset years,” the future president cautioned, “telling our children and our children’s children what it once was like in America when men were free.”
Nothing of the kind occurred after President Lyndon Johnson and Congress enacted the Medicare program in 1965. On the contrary, assured healthcare coverage for the elderly has become an ineradicable feature of the American landscape.
Hyperbolic warnings of disaster killed President Bill Clinton’s national healthcare proposal in the 1990s, and later slowed President Barack Obama’s push for the Affordable Care Act. In the latter case, Republicans capitalized on many of their white supporters’ antipathy for the first Black president by invoking “Obamacare” as an epithet.
They mocked then-House Speaker Nancy Pelosi for saying Americans would appreciate the program once it passed and they discovered its contents. In fact, that’s exactly what happened.
Thus, in 2017, President Trump and a Republican Congress couldn’t pull off their top priority – repealing Obamacare. Three Republican senators joined Democrats in refusing to strip benefits their constituents had grown accustomed to, including subsidized individual policies, a guarantee that those with pre-existing conditions could obtain coverage, and the ability for children to stay on their parents’ policies until age 26.
Moreover, Obamacare actually expanded due to popular demand.
Half of the program – the subsidized private policies offered through ACA “marketplaces” – has operated in every state since 2014. But the other half – new benefits for low-income Americans through Medicaid – was left optional for states under a Supreme Court ruling.
Red States Expand Medicaid
By the end of Obama’s administration, most states had chosen to expand Medicaid. And remarkably, the lingering resistance of red states began melting on Trump’s watch.
Voters circumvented the opposition of Republican elected officials by approving Medicaid expansion through ballot initiatives in six states. These included such stalwart GOP electorates as Oklahoma, which Trump won in 2016 with 65% of the vote, Idaho (59%), Nebraska (59%) and Missouri (57%).
The momentum has continued under President Biden. Not long after taking office, Biden pushed through increases in Obamacare subsidies for marketplace customers and states that belatedly expanded Medicaid. South Dakota – where Trump won with more than 61% of the vote in 2020 – did so via a ballot measure in 2022. In North Carolina, Democratic Gov. Roy Cooper finally persuaded the Republican-controlled General Assembly to expand the program last year.
The result? Some 45 million Americans have obtained health insurance under Obamacare from either marketplaces or Medicaid. The proportion of the population without health coverage has dropped by more than half to 8%.
Distance from the program’s lightning-rod author may have tempered conservative opposition. “Fourteen years out, the association of it with Obama has finally started to fade,” says Larry Levitt, executive vice president for health policy at the Kaiser Family Foundation.
“A Turning Point”
Just 10 states continue to hold out. Six are in the Deep South, which traditionally provides meager public services for their poor and working-class residents.
But economic conditions combined with simple human needs have altered the equation. In Mississippi, a mid-2023 study reported that nearly half the state’s rural hospitals were in danger of closing. Prominent business leaders have joined the medical community and faith-based activists in calling for Medicaid expansion.
They still face hard-right opposition in a state that voted nearly 58% for Trump in 2020. If the House and Senate pass their compromise expansion plan, Republican Gov. Tate Reeves has promised to veto it, saying it amounted to more “welfare.”
Yet the fact that Mississippi politicians have come this far shows that these tangible benefits for financially-strapped Americans have grown increasingly hard to oppose. In North Carolina, whose expansion Mississippi has used as a model, 400,000 residents have gained Medicaid health coverage in recent months.
“I see North Carolina as a turning point,” observed Nancy-Ann DeParle, a key architect of the ACA in Obama’s White House. “You had Republican legislators finally seeing that the policy and the politics both argue for expanding Medicaid. [That] gives other Southern states a sort of ‘permission slip’ and playbook to follow.”
The reversal of fortune signals the potency of healthcare as a campaign issue for Biden this year. Trump knows it. Unlike 2016, he recently said that he is “not running to terminate” Obamacare in 2024.
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Wow, I didn't realize there were still so many holdouts. It will never cease to amaze me how our government continues to use ignorance and racism to keep down those they claim to champion. When will people experiencing poverty and the working class understand that Republicans and populism are antonyms?
NC is also the only state with a Republican-legislature that passed a law codifying a GHGs reduction and major support for solar.