In this Oct. 17, 2018 photo, a yard sign promoting Initiative 427, the Medicaid Expansion Initiative, is seen in Omaha, Neb. For nearly a decade, opposition to Obama's health care law has been a winning message for Nebraska Republicans, helping them take every statewide office, dominate the Legislature and hold all of the state's congressional seats. But in the upcoming general election, even the most strident opponents of the Affordable Care Act are acknowledging an odd reality: there's a good chance the voters who support them will also approve a ballot measure expanding Medicaid. (AP Photo/Nati Harnik)
In this Oct. 17, 2018 photo, a yard sign promoting Initiative 427, the Medicaid Expansion Initiative, is seen in Omaha, Neb. For nearly a decade, opposition to Obama's health care law has been a winning message for Nebraska Republicans, helping them take every statewide office, dominate the Legislature and hold all of the state's congressional seats. But in the upcoming general election, even the most strident opponents of the Affordable Care Act are acknowledging an odd reality: there's a good chance the voters who support them will also approve a ballot measure expanding Medicaid. (AP Photo/Nati Harnik)

More than 4 million people have enrolled in Medicaid coverage during the coronavirus pandemic, a key reason why the nation’s uninsured rate does not appear to have dramatically increased in 2020.

Imagine losing your health insurance during the worst pandemic in a century—one that has, as of this writing, claimed the lives of 374,000 people in the United States, infected more than 22 million, and left countless others with costly medical bills.

For many Americans, this situation isn’t a hypothetical, it is their reality. While exact estimates vary, millions of people lost their jobs and the employer-sponsored health insurance that provided coverage for themselves or their families. 

Sonjya Reynolds is one of them. When her husband Matt lost his job last March due to the coronavirus pandemic, the Pleasant Grove, Utah family also lost their coverage from Blue Cross. 

Having at times relied on public insurance over the years, Reynolds knew she could enroll all nine of their children ages 6 to 19—including two adopted children and two foster children—in Medicaid, which offers insurance to low-income adults and children. But when that’s happened in the past, Sonja and Matt have been ineligible for the program themselves and had to go without coverage—a less-than-ideal scenario in the middle of a public health crisis. 

And had the pandemic occurred a year earlier, they may have had to roll the dice and do exactly that once again. But when Utah residents went to the polls in 2018, they bucked their Republican leaders and voted to expand Medicaid under the Affordable Care Act, extending coverage to adults earning up to 138% of the federal poverty line, which included more than 100,000 Utahns. That expansion was fully implemented in January 2020. After Matt lost his job, he and Sonja became eligible and were able to enroll in coverage, providing an enormous safety net during the pandemic. 

Sonjya and Matt Reynolds (COURIER illustration / Denzel Boyd)

Reynolds, who works full-time as a private music teacher, said their Medicaid coverage has provided a huge sense of relief. “I was really grateful for the Medicaid expansion,” she told COURIER. “When we’ve been on Medicaid before, it was stressful because my kids were on it, but [my husband and I] had no health coverage. We were like, ‘Let’s hope we don’t get sick.’ It’s stressful to not have it.”

The Rare Bright Spot In a Pandemic

While the federal government’s response to the pandemic has been a complete catastrophe, the Medicaid program has been a rare bright spot. More than 4 million people have enrolled in Medicaid coverage, a key reason why the nation’s uninsured rate does not appear to have dramatically increased in 2020. 

That reality underscores a growing truth: Even though Republicans have spent a decade attacking the Affordable Care Act and many GOP-led states have refused to expand Medicaid, the program has been a quantifiable success.

Research has shown Medicaid expansion has saved tens of thousands of lives, improved health outcomes, made it easier for people to pay bills, and reduced rates of food insecurity, poverty, and evictions in states that expanded coverage.  

The program is also enormously popular, even in deeply conservative states like Utah and Idaho. In 2018, 61% of voters in Idaho also chose to expand Medicaid, just two years after nearly the same percentage voted for President Donald Trump. As a result of this successful ballot initiative, Lisa Hardy was able to enroll and obtain coverage through the expansion last summer. 

The 62-year-old Hardy was living in Kellogg, Idaho at the time, a rural county of about 12,000. She had just wrapped up her second year in the AmeriCorps vista national service program, during which she had relied on Affordable Care Act marketplace plans for insurance. When her time in the program ended, however, her lack of income meant she might no longer be able to afford her ACA plan.

But because Idahoans embraced expanding Medicaid in overwhelming numbers two years earlier, Hardy was eligible to enroll. 

“When I went to the state to report a change in life circumstance, the state said, ‘Oh, we’re signing you up for Medicaid,’” Hardy told COURIER. “The state Department of Health and Welfare did a really good job. It was really seamless to sign up for that.”

Lisa Hardy (COURIER illustration / Denzel Boyd)

She was one of more than 96,000 Idahoans to get coverage via the expansion in 2019. Hardy only relied on Medicaid for two months of coverage in July and August, as she was offered and accepted a full-time position with health benefits in September.

But even having coverage for those two months was important to Hardy, who has never gone without insurance. “I was always very careful to keep insurance,” she said. “I always figured something terrible would happen if you know it’s lapsed for one month, that would be the month that I would get in a car wreck or something.”

Hardy, who relocated to Nevada for her new job, expressed gratitude for the expansion, which allowed her to maintain coverage during the pandemic. 

‘How Do You Win Progressive Policy in Deep Red States?’

Reynolds and Hardy’s stories highlight the importance of efforts to expand Medicaid. While nearly all Democratic-led and a few Republican-led states embraced expansion soon after the ACA went into effect, many red states opted not to expand their programs, even though the federal government covered all costs related to expansion from 2014-2017 and now covers 90% of costs.

That opposition is why, beginning in 2016, a coalition of healthcare advocates and groups led by The Fairness Project, a nonprofit organization focused on economic and social justice, began taking the choice directly to voters. The group, which focuses on placing state-level initiatives on ballots, has been remarkably successful, winning 20 out of 21 campaigns in just four years.

Many of those victories—including successful Medicaid expansion ballot measures in Idaho, Maine, Missouri, Nebraska, Oklahoma, and Utah—have come in conservative states, which raises a key question: How do you win progressive policy in deep red states?

“The answer is that The Fairness Project strips the party labels off of the policy and gets people to think about these fundamental questions: Do you want to raise wages? Do you want to expand Medicaid and healthcare? Do you want to provide sick leave?” Jonathan Schleifer, executive director of the Fairness Project, told COURIER. “What we’ve found is every time we’ve asked those questions of voters, they say yes. When we excuse them of the pressures of partisanship and ideology, we find that Americans tend to be much more generous than our politics or Twitter suggests.”

The group doesn’t do this work on its own. Instead, it partners with local organizations to develop the ballot measures, build out a campaign infrastructure, develop grassroots public support, raise money to fund the campaigns, educate voters, and get out the vote. 

Nebraska Appleseed, a nonprofit legal advocacy organization focused on social justice efforts, including expanding healthcare, was one of these local partners. The organization had been working to expand Medicaid in Nebraska since 2013, but faced opposition from the Republican-led legislature. That ultimately prompted the push for a ballot measure.

“The way that we always perceived this, and I think really played out in the initiative, is that the opposition that we saw in the legislature didn’t seem to be reflective of what constituents actually felt about this issue,” Molly McCleery, director of Nebraska Appleseed’s health care access program, told COURIER. “That’s why we took it to the people, because we felt like people were supportive of the issue, even if their representatives weren’t.”

Like Schleifer, she believes that voters fundamentally have a different approach to policy questions than lawmakers, which is why their effort was successful.

“I think when individual people talk about health care and they think about health care, they think about how it impacts them personally or impacts their family and I think that gets past some of the kind of policy conversations that may be happening in the legislature or in Congress,” McCleery said. “I think the big thing that we learned about this and was validated in our work on this is that it really is people caring about their community and caring about people getting coverage.”

What the success of these ballot measures across conservative America shows, according to Schleifer, is that people want more health care, not less, and are tired of politicians who are taking their cues from donors, lobbyists, and special interests rather than their constituents. 

‘Medicaid Expansion Has Profoundly Changed the Lives of Millions of People’

Without The Fairness Project and local partners like Nebraska Appleseed, it’s an open question of whether Reynolds, Hardy, and tens of thousands of others in conservative America would have maintained some form of insurance coverage during the pandemic. That the pandemic has made their victories even more important is not lost on Schleifer.

“When your healthcare is tied to your employment, if you’re living through a health care crisis and you don’t have a job, that is potentially one of the most vulnerable places a family can be in,” Schleifer said. “Knowing that there is a social safety net that can cover you during those times is life changing.”

McCleery has also heard anecdotes of the expansion’s positive impact on enrollees, since coverage began in October. While exact enrollment data is not yet available, an estimated 90,000 Nebraskans were projected to be eligible for expansion before the pandemic. Due to the pandemic’s economic devastation, that number could now reach as high as 140,000, according to McCleery. 

“That’s a really big chunk of our population that could be touched by this program, so I think just on the basic level of getting people covered who don’t have other coverage options, this is so important,” McCleery said. 

Despite the clear benefits of expanding the program, only 36 states and Washington DC have implemented Medicaid expansion thus far, with Missouri and Oklahoma in the process of doing so. That leaves 12 others, including four of the 10 most populous states—Florida, Georgia, North Carolina and Texas—where Republican-led legislatures have refused to enact expansion. This obstruction has frustrated Schleifer precisely because the stakes are so high. 

“I find the persistent opposition to Medicaid expansion in some of these states to be heartbreaking, frankly, because every year that a state doesn’t have Medicaid expansion literally means people’s lives are lost,” Schleifer said. “Medicaid expansion has profoundly changed the lives of millions of people, so the political opposition to it is just tragic.”

‘It’s What Americans Need Right Now’

Republican opposition, however, does not concern Schleifer when it comes to the future work of his organization. Four of the 12 states without expansion currently allow for a ballot measure process and The Fairness Project is already working with local groups to advance initiatives in three of those states—Florida, Mississippi, and South Dakota—in 2022. 

Schleifer is confident about the organization’s prospects in those states, noting that each win builds momentum and makes the coalition bigger, stronger, and more enthusiastic, regardless of what political leaders in those states may say. 

“The beauty of a ballot initiative is the governor and the speaker of the house who are getting signals from special interests, who are getting signals from the party, who are getting signals from ideologues—they only get one vote,” Schleifer said. “And it’s the same vote that the person who cuts their hair gets and it’s the same vote that the person who checks them out at the grocery store gets—the very people who are going to benefit from Medicaid expansion. So we don’t really worry about the political opposition, because the only votes that matter go to the people.”

As for the states that don’t have a ballot process, Schleifer hopes that eventually, as they become an “ever-shrinking minority,” the political tides will change and the leaders of those states will face pressure to implement expansion. 

Reynolds and Hardy, who respectively consider themselves a “middle of the road” voter and an “independent”, are hoping for the same. And they have been frustrated to see health care become a partisan issue with Democrats working to expand it and Republicans working to repeal the ACA. 

“I wish people could just see it as a social program like public education or public roads or any other social program that we have that benefits everybody,” Reynolds said. “If we could be on Medicaid forever—that’s what everybody deserves. It’s great.”

Hardy, meanwhile, described the current employer-sponsored insurance system as irrationally “wacky” and said she supports a single-payer system like the one Canada has. That sort of system would mean a world of difference for her and millions of others, who feel obligated to take or stay in jobs they might not otherwise do solely for insurance coverage. 

“Don’t get me wrong. I love my job here, but a big reason for taking this job is because I just did not want to have to worry about health insurance anymore,” Hardy said. “I could be doing other things … but it’s just insane—the healthcare system in this country.”

That insanity has been laid bare by the coronavirus pandemic. So too has the role publicly-run insurance can play in improving upon it and providing people with stability. 

“We’re living in the time of unexpected bills right now, and people aren’t getting paid as much as they were before, or they’re just not getting paid at all because they lost their jobs. And so being able to ensure that people have healthcare is probably one of the greatest responsibilities that the government has,” Schleifer said. 

Many Republican-led states—and the federal government under Trump have—not only failed in that responsibility, but have expressed open hostility towards it and refuted that it’s a responsibility at all. That has opened a void that Schleifer and The Fairness Project plan to continue to fill for as long as is necessary. 

“We’re just so excited to be able to, time and time again, find a way to go around the broken political system and then deliver that health care to people because we know it’s what voters want,” he said. “And we know it’s what Americans need right now.”