Skip to content

Student perspective: What’s up with Medicaid Expansion in Conservative States?

by Sonia Bat-Sheva Kaufman

News stations like to discuss how U.S. states can neatly be divided into “blue” and “red” territories. In theory, blue states support abortion access, expanded social welfare programs, and measures like Medicaid expansion. Red states do not. However, voting records and polling indicates that the views of people living in states are much more complex than the simple “blue/red” divide would indicate. Medicaid expansion is just one instance through which we can examine this contradiction.  

Medicaid is a government-funded health insurance option for low-income Americans. It is a federal-state partnership, meaning that the federal government sets rules and provides most of the funding, but each state administers its own Medicaid program. The federal government established Medicaid in the 1960s, and it originally covered only specific categories of low-income people, such as parents, pregnant women, and people with disabilities. The Patient Protection and Affordable Care Act (ACA) in 2010 was the most significant Federal push to expand Medicaid beyond these categories; it incentivized states to allow childless adults to enroll and increased the income cutoff. Most states did expand, as increased federal funding convinced even Republican-led states to expand eventually. However, there are still ten states – all with Republican legislatures – that have not expanded Medicaid.

At first glance, Medicaid expansion may seem like an excellent example of the blue/red divide among states – but there’s more going on here. Arizona, for example, was way ahead of its time; it was one of the first states to expand Medicaid to childless adults—a full nine years before the ACA when Republican and Independent voters outnumbered Democrats by nearly two-thirds. And it passed through a ballot measure that went directly to the voters.

According to national party platforms, Medicaid expansion is a Democratic policy. Democratic gubernatorial candidates have embraced Medicaid expansion as well. Conversely, Medicaid expansion is not part of the national and state Republican party platforms, and while nearly all non-expansion states are “red,” 38% of states that have expanded Medicaid had Republican-led legislatures and/or governors at the time of expansion (15 out of 39 states). Another six Republican-majority states implemented Medicaid expansion through ballot initiatives. Meaning, that Medicaid expansion has been enacted in as many red states as blue states.

All ten non-expansion states have Republican-led legislatures and/or governors who oppose expansion. Yet, in some cases, we see slippage in these positions among Republican elected officials. For example, Republican leaders in North Carolina recently announced a bi-partisan agreement for Medicaid expansion, and Kansas and Wyoming may soon follow.

Further, almost all states that allow ballot initiatives have expanded Medicaid. State ballot initiatives – otherwise known as ballot measures and propositions – are legislative proposals that go directly to the voters and are available in twenty-one states. Just last year, bright red South Dakota voted to expand Medicaid by 56%. Most notably, in every state where voters have had a direct say in the vote, Medicaid expansion has passed. Only Florida and Wyoming remain as states with ballot initiatives that have not yet had a vote. Other states that have passed Medicaid expansion by ballot initiative include Missouri (passed in 2020), Oklahoma (2020), Nebraska (2018), Utah (2018), and Idaho (2018). These are majority Republican voters – in red states – saying yes to Medicaid.

Medicaid expansion is just one example of Democratic platforms having overwhelming bipartisan support; other examples include abortion access, minimum wage increases, gun safety regulations, and protecting the environment. Why do these issues poll so well, but Democrat-controlled state legislatures are so few and far between? Well, that’s a complicated story. Some advocates argue that congressional gerrymandering plays a big part, as legislators no longer need to compete across diverse voting groups. Others point to how partisan primaries push candidates to the extremes, especially on the right. Due to extreme gerrymandering, partisan primaries are oftentimes the only ways to hold politicians accountable. Yet only a thin slice of the electorate has a say – or even participates – in these primaries that have ramifications statewide and nationally. It’s become so extreme that in 2020 10% of the U.S. electorate decided the winners in over 80% of districts. This means that Republican politicians may be much more conservative than the average conservative voters.

Despite Democrats proposing more economically populist measures, Republicans maintain a populist reputation, while Democrats are sometimes viewed as ‘out-of-touch elites.’ In this vein, even when Democrats champion popular economic messages, historical Democratic economic decisions – such as the North American Free Trade Agreement (NAFTA) of 1994 – can overshadow their popularity. It remains a big question why conservative economic measures don’t get the same treatment.

In the meantime, for Democratic candidates to usurp the economic populist throne, they must draw contrasts with their opponents and perhaps return to a New Deal-type economic messaging. Some Democratic candidates have already done so with success. One example that stands out is John Fetterman of Pennsylvania, who ran for the Senate in 2022 on a populist platform and consistently showed up at union drives across the state. Perhaps some lessons can be taken from his success in a purple state: he campaigned on popular issues across the political spectrum, including universal healthcare coverage. One of the reasons he won is because his views are widespread. 

Democrats shouldn’t be afraid to go to bat for their popular views and draw contrasts with their opponents. As just one example, Medicaid expansion is wildly popular across all political groups. At this point, if states do not pass Medicaid expansion, it reflects the state government more than the people. When Republican, Independent, and Democratic voters get a direct say, Medicaid is expanded. It is for this exact reason that Republican-led states – regardless of whether they have direct ballot initiatives – should pass Medicaid expansion. It’s popular, life-saving, and even saves states money. Medicaid expansion has resulted in over 12 million Americans becoming insured and 12 fewer deaths per 100,000 annually. Lives have been saved in every state that has expanded Medicaid. A 2021 study found that as many as 7,000 more lives could be saved annually if the remaining non-expansion states implemented Medicaid expansion. There would also be 48,640 fewer evictions annually due to medical debt. The facts paint the picture clearly: Americans die daily due to these state politicians’ inaction.

For Florida and Wyoming, the two remaining states that have not implemented Medicaid expansion but have viable ballot initiatives, history is on the side of expansion. No matter how difficult state Republican leaders try to make it, how many restrictions are in place, or how long it will take, Medicaid expansion is a priority for the Republican voting base, let alone for Independent and Democratic voters. Perhaps as a result, more Republican legislators seem to be coming around, but it will take pressure from all voters to get them there. Republican voters = more Medicaid. Who knew?

Sonia Bat-Sheva Kaufman

Sonia Bat-Sheva Kaufman is a Ph.D. student at the University of Arizona studying Geography and Public Health Policy. Her research centers on state and local environmental and health issues, and her dissertation examines the social, racial, and gender dynamics around street litter in Philadelphia, PA. Before beginning graduate school, Sonia worked as a sexual violence hotline and hospital advocate.

* * *

This post is authored by a University of Arizona student and does not reflect the opinions of AHPI or the University of Arizona.