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Health care is on the ballot in state elections

The fate of Medicaid expansion is on the line in three Southern states.

Health care on the ballot. Zac Freeland/Vox

The races for governor Tuesday, November 5, in Kentucky and Mississippi haven’t attracted nearly as much attention as next spring’s presidential primaries, but they are hugely important to hundreds of thousands of voters without access to health care.

Leaders in those states have rejected or put tough restrictions on extremely generous federal matching funds allocated under the Affordable Care Act (ACA) to extend their Medicaid programs to cover families earning up to 133 percent of the federal poverty level. Depending on who becomes governor in these states, that could change or solidify. State legislative elections in Virginia, meanwhile, have their own set of implications for that state’s health care programs.

The stakes are very real. A recent study from four researchers — University of Michigan economist Sarah Miller; University of California, Los Angeles public health scholar Laura Wherry; National Institutes of Health’s Sean Altekruse; and Norman Johnson with the US Census Bureau — estimates that failure to expand Medicaid leads to about 15,600 extra deaths per year just among people ages 55-64.

After the passage of the ACA, Democratic states mostly took the expansion money, adding over 7 million more Americans to insurance rolls in recent years. GOP-run states mostly didn’t, though a handful of GOP governors have accepted expansion funding but done so under waiver systems that let them impose heavy work requirements and other administrative burdens on recipients.

Originally, the ACA stipulated that states that failed to expand Medicaid would lose their existing federal funding, which would have made expansion all but inevitable. But a 6-3 Supreme Court ruling in which four conservative justices were joined by liberals Stephen Breyer and Elena Kagan struck down that punitive aspect of ACA expansion as unconstitutional.

The decision set off a years-long series of state-by-state battles with very real stakes. Next week several of those fights are coming to a head.

Work requirements on the line in Kentucky

In Kentucky, Republicans want to keep new work requirements for Medicaid recipients and Democrats want to lift them.

The state expanded Medicaid at the first possible opportunity back under then-Gov. Steve Beshear, a Democrat. His successor, Matt Bevin, got a waiver from the Trump administration to impose stringent work requirements that are currently being held up in court. A comprehensive study in the New England Journal of Medicine of a similar program in Arkansas found that work requirements reduce enrollment and raise the uninsured rate without doing anything to increase employment.

It seems likely that if Bevin is reelected he will prevail in what’s an increasingly conservative-dominated federal judiciary.

Bevin’s opponent is Beshear’s son, Andy, who is also the state’s attorney general. Andy Beshear opposes Bevin’s changes to Medicaid and could recapitulate his father’s success in driving the Kentucky uninsurance rate down to record lows.

Mississippi: A Democrat could expand Medicaid

A Democrat winning a statewide race in Mississippi sounds unlikely, but the party has a strong candidate in longtime Attorney General Jim Hood, and the (scant) polling has shown a tight race between him and Lt. Gov. Tate Reeves.

Mississippi has one of the lowest health insurance rates in the country (45th out of 50) and the lowest median household income.

Consequently, the upside to Medicaid expansion — which would both cover many people and provide a large injection of federal money into the state economy — is large, and Hood is pushing strongly for it.

Beyond the specific consequences for Mississippi, the mere fact that it’s such a long-shot race would send a clear signal about the potency of the Medicaid expansion as an issue.

Virginia: Control over the state legislature

Virginia has acted as mostly a blue state in recent years, voting for Barack Obama twice and then Hillary Clinton, sending two Democratic senators to DC, and electing two Democratic governors in a row. But in part because of aggressive gerrymandering, the state legislature has remained in GOP hands for years.

Former Democratic Gov. Terry McAuliffe tried repeatedly to expand Medicaid but was blocked by the legislature. His successor, Ralph Northam, got it done after Democrats picked up a few seats in 2017, but he had to make some compromises limiting eligibility.

Republicans currently hold narrow two-seat advantages in both the state Senate and the House of Delegates, but Northam carried strong majorities in districts for both houses during his 2017 election. That, plus strong fundraising and polling that seems to show Trump has become even less popular in Virginia over time, makes Democrats very optimistic about the ability to flip both chambers despite the cloud of scandal hanging over their statewide elected officials.

The implications of a possible flip in control are wide-ranging. Having power over the redistricting process after the 2020 census would be especially significant, but so is health care. A Democratic state legislature would likely lift those restrictions on eligibility and could even join other Democratic-run states in experimenting with larger expansions of government-provided health insurance.

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