All Medicaid expansion politics is local

In this morning’s Wonkbook, Ezra Klein suggests that the Medicaid eligible in states that don’t expand the program might turn out to be a meaningful political force.

It’s a truism of health-care politics that the uninsured are impossible to organize. But Obamacare creates an extraordinarily unusual situation. The Affordable Care Act will implemented in states that reject Medicaid. There will be huge mobilization efforts in those states, too, as well as lots of press coverage of the new law. The campaign to tell people making between 133 and 400 percent of poverty that they can get some help buying insurance will catch quite a few people making less than that in its net. And then those people will be told that they would get health insurance entirely for free but for an act of their governor and/or state legislature.

I’d keep an eye on how provider associations — particularly hospitals — respond. They’re the groups that both have something to lose here and are organized to do something about it. I’d keep half of my second eye on insurers. Even though Medicaid can be expanded as a public program, it could also be expanded in a way that throws more business toward insurance companies (e.g., Arkansas’s private option).

If insurers and providers put their lobbying muscle and money where their interests are, they might swing none too few local elections in a way that favors expansion. That’s when the Medicaid dam may break. The next set of state and local election cycles could be very interesting.


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