A choice be­tween re­al­ity and rhetoric

Vot­ers in Idaho, Ne­braska and Utah have the chance to force Repub­li­cans’ hands on Med­i­caid ex­pan­sion.

The Washington Post Sunday - - SUNDAY OPINION -

IF THE pol­i­tics of health care over the past two years has proved any­thing, it is that Amer­i­cans gen­er­ally want the gov­ern­ment to en­sure that ev­ery­one has ac­cess to de­cent cov­er­age, par­tic­u­larly the most vul­ner­a­ble. The midterm elec­tions Tues­day will test how deep into GOP ter­ri­tory that at­ti­tude ex­tends.

Vot­ers in Idaho, Ne­braska and Utah — three of the na­tion’s most Repub­li­can states — will de­cide whether to ex­pand Med­i­caid within their bor­ders. The fed­eral-state part­ner­ship covers low-in­come Amer­i­cans, and Oba­macare ex­panded the number of peo­ple el­i­gi­ble for the pro­gram. Or it tried, any­way. The Supreme Court in 2012 made ex­pan­sion op­tional for states, and a sur­pris­ing number of red-state politi­cians re­fused to boost their Med­i­caid rolls, leav­ing mil­lions of Amer­i­cans with no rea­son­able health in­sur­ance op­tion, even with the rest of Oba­macare in place. There was never a good rea­son to refuse: the fed­eral gov­ern­ment picks up nearly all of the tab in ex­pan­sion states, and the rel­a­tively small amount states must spend is off­set by big sav­ings on other health-care ex­penses for which states would have oth­er­wise been re­spon­si­ble.

Op­po­si­tion to ex­pan­sion turned out to be un­pop­u­lar as well as ir­ra­tional, per­haps be­cause the case for re­fus­ing was so bad and the costs to those af­fected so steep. Slowly but surely, GOP-led states have ac­ceded to re­al­ity. Even Vice Pres­i­dent Pence, when he was gov­er­nor of In­di­ana, ex­panded Med­i­caid in his state. Af­ter a crush­ing slap from vot­ers last year, Virginia Repub­li­cans fi­nally ended their re­sis­tance to ex­pan­sion. Nev­er­the­less, rote GOP op­po­si­tion to Oba­macare has led 17 other states to con­tinue hold­ing out.

So or­ga­niz­ers in three states de­cided to adopt a strat­egy that worked in Maine, whose re­ac­tionary Repub­li­can gov­er­nor, Paul LePage, staunchly op­posed ex­pan­sion: ask­ing vot­ers di­rectly. State-level bal­lot-ini­tia­tive sys­tems are dou­ble-edged swords, at best, and of­ten re­sult in poorly-vet­ted pol­icy that ham­strings leg­is­la­tures. But this is a case in which by­pass­ing ob­struc­tion­ist state lead­ers makes sense.

Ac­cord­ing to the Kaiser Fam­ily Foun­da­tion, some 22,000 peo­ple in Idaho, 16,000 in Ne­braska and 46,000 in Utah cur­rently fall into the “cov­er­age gap” — that is, they make too much to qual­ify for non-ex­pan­sion Med­i­caid, but too lit­tle to qual­ify for Oba­macare in­sur­ance sub­si­dies. If vot­ers in these three states de­cide Tues­day to ex­pand their Med­i­caid pro­grams, these peo­ple will fi­nally have a health-care op­tion that doesn’t in­volve go­ing into debt or re­ly­ing on emer­gency rooms for care that should have been ad­dressed else­where.

It is rare that vot­ers have an op­por­tu­nity to so di­rectly and im­me­di­ately help tens of thou­sands of peo­ple. If the Idaho, Ne­braska and Utah ini­tia­tives suc­ceed, it will be a vic­tory for re­al­ity over rhetoric.

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