A Victory Lap for Obamacare at the Ballot Box

In Donald Trump’s America, government-run health care isn’t in retreat—it’s on the march.

Voters in Maine on Tuesday decisively chose to expand Medicaid under the Affordable Care Act to more than 70,000 additional residents, overruling a conservative governor who vetoed similar measures five separate times. In Virginia, health care buoyed Democrat Ralph Northam to a nine-point victory, with exit polls showing the issue was far and away the most important for voters. And across the country, early indications are that consumers are enrolling in insurance plans on the Obamacare exchanges in record numbers, confounding expectations that sign-ups would plummet following attempts by the Trump administration to dismantle the law.

Taken together, the developments paint a startling picture just a year after voters elected Republicans to the White House and to Congress on the promise of reducing the government’s role in health care by repealing and replacing the Affordable Care Act.

The most direct change occurred in Maine, which will become the 32nd state to adopt the ACA’s Medicaid expansion after voters there approved a ballot initiative by a margin of nearly 18 points, 59 percent to 41 percent. The state is the first to expand Medicaid on a statewide referendum rather than in the legislature. “It’s a critical shift in the fight for health care,” said Jonathan Schleifer, executive director of the Fairness Project, an advocacy group that backed the ballot initiative. “At a time when everyone was expecting health care to go in one direction, with fewer people covered and higher costs, Mainers took it in the opposite direction last night.”

Their campaign now moves to red states like Utah, Idaho, and Nebraska, where activists plan new pushes to put Medicaid expansion on the ballot in 2018. In Alaska, there’s already a movement for state voters to protect the state’s expansion from federal cuts in Congress. “The victory [Tuesday night] is going to fuel a movement across the country to expand and lock in Medicaid and bring health care to millions of people,” Schleifer said in a phone interview Wednesday.

The ACA made billions of federal dollars available to states that increased eligibility for the program that provides health care to poor and low-income Americans. The Supreme Court ruled in 2012 that the expansion must be voluntary for states, and many controlled by Republicans opted out.

Tuesday’s results are also giving new hope for action by state legislatures, where efforts to expand Medicaid have stalled amid fights over ideology and budgetary constraints. In Virginia, outgoing Democratic Governor Terry McAuliffe has been unable to pass a Medicaid expansion through the Republican-controlled legislature. But because of more than a dozen Democratic pickups in local races on Tuesday, Northam could have a narrow majority in the House of Delegates and more leverage to pressure the state Senate, where Republicans have a slim advantage.

And in Kansas, a coalition of moderate Republicans and Democrats could make another push to expand Medicaid when the legislature reconvenes in January. Earlier this year, the state House and Senate fell just a few votes shy of overriding Governor Sam Brownback’s veto on an expansion bill.  State Representative Susan Concannon, a Republican who led the Medicaid push, said many supporters were discouraged in the spring and summer by the continued efforts in Congress to repeal Obamacare and felt it was “too late” for the state to expand Medicaid. But with the repeal drive shelved and after the vote in Maine, the dynamic may change. “For us in Kansas, it really is an inspiration that they were persistent,” she told me on Wednesday. “It’s something that we can point at as a success.”

The most surprising development in the health-care wars, however, may be happening in the marketplace rather than the ballot box. According to multiple reports, enrollment in the Obamacare insurance exchanges surged during the initial days of this year’s sign-up period, which began November 1. Analysts had expected enrollment to fall amid reports of sharp premium increases and a decision by the Trump administration to slash the budget for outreach and advertising by 90 percent. In response, ex-Obama administration officials set up their own public-awareness campaign, which included a video recording by the former president.

But those involved in the effort attribute the spike in enrollment to a quirk in the way the Trump administration has managed the law. Trump’s decision to withhold payments to insurers ended up triggering higher direct subsidies for consumers. As a result, people in some areas can find high-deductible plans with much lower premiums, or even no monthly payments at all. “For many people, the premiums are lower than they ever have been before,” said Lori Lodes, co-founder of the advocacy group Get America Covered. The additional cost is to taxpayers, meaning the Trump administration’s decisions are ultimately increasing the federal government’s hand in health care, at least in the short term.

The ACA, of course, still faces many challenges. The initial spike in enrollment may be short-lived. People who do not qualify for government assistance are likely to be on the hook for much higher costs. Republicans could make another run at repealing the law early next year, an effort that might short-circuit state efforts to expand Medicaid legislatively.

And even in Maine, the fight over Medicaid isn’t over. Governor Paul LePage, the conservative who vetoed expansion bills five times, reacted defiantly to the vote his constituents took against his explicit wishes. In a statement Wednesday morning, he said the decision would be “ruinous” to Maine’s budget and that he would not implement the expansion until it had been “fully funded” by the legislature. Opponents of the referendum allied with LePage had argued expanding Medicaid would force the state to make cuts to programs benefitting the poor. “You can’t squeeze ketchup out of a turnip,” said Brent Littlefield, a former LePage adviser who ran the opposition campaign.

Backers of the initiative, however, were unbowed. “The legislature will move swiftly to fund Medicaid expansion as required by law,” responded Sara Gideon, the Democratic speaker of the state House. “Any attempts to illegally delay or subvert this law will not be tolerated and will be fought with every recourse at our disposal. Mainers demanded affordable access to health care [Tuesday], and that is exactly what we intend to deliver.”

David Farmer, a spokesman for the pro-expansion group Mainers for Health Care, told me the ballot measure would, by law, take effect 45 days after the legislature reconvenes in January and that the state government must implement expanded Medicaid eligibility within 180 days after that. “The governor cannot ignore the law or the constitution of Maine. He can’t do it,” Farmer said. He characterized LePage’s typically combative statement as more bluster than proclamation. “It may or may not be illustrative of what he actually intends to do,” Farmer said. “As we’ve seen in Maine, the governor says a lot of things.”

In Maine and elsewhere, Democrats took comfort in elections in which voters turned out not merely to defend gains already won in health care, but to expand them to others. “The cynical vision that says people aren’t willing to stand up for their neighbors and only act when it’s in their self interest is actually not a fair representation of Americans,” Schleifer said, “and Mainers proved that last night.”