The healthcare issue that Democratic presidential candidates are missing

Health care in the Democratic presidential debates has largely focused on Medicare for All versus the more incremental public option. 

Medicare for All has great appeal to many Democrats, but struggles with other voters. The concept of a public option is less risky but also less mobilizing. Each Democratic alternative, whether Medicare for All or the public option, would require new legislation.

If only there were a policy on health care with the legislative lift already done that appeals to voters across partisan lines and that voters know and like, and I don’t mean the Affordable Care Act, also known as Obamacare, which is more popular than it was, but is still fairly obscure to voters with support that still falls along partisan lines.

That policy exists. It’s called Medicaid.  Or the “M Word.” Or “the policy that shall not be named” to judge from the Democratic presidential debates.

Created along with Medicare in 1965, Medicaid covers more than 75 million Americans. The Affordable Care Act expanded Medicaid eligibility up to 138% of the poverty level and covered the vast share of the cost. 

The Affordable Care Act essentially turbo charged the long-standing Medicaid program. After the Supreme Court ruled that states could choose the expansion, it became a state by state political struggle. Thirty-seven states have now adopted the expansion. 

The Kaiser Family Foundation has found that Medicaid expansion dramatically reduced the uninsured population and improved health, especially in rural areas. States that adopted it have reported health improvements largely absent in the holdout states. 

Especially in California. Medicaid expansion, through Medi-Cal, has contributed in a major way to bringing full coverage in sight. 

In 2013, 19% of California residents were uninsured. Now, that number is about 7%.

Of the state’s nearly 40 million residents, 13.2 million are enrolled in Medicaid, including half of the state’s children.  

According to the California Budget & Policy Center, 40% of L.A. County residents are covered by Medi-Cal. In Fresno, that number is 49.9%, and in Kern County, it’s 45.1%.

This record should be part of what candidates talk about in the California primary race, especially in vote-rich Southern California.  

The Kaiser Family Foundation national surveys have shown that Medicaid has become increasingly popular across party lines and that it is nearing the public support for Social Security and Medicare.  

Medicaid is substantially more popular than the Affordable Care Act. While voters may not know that the Medicaid expansion was part of the Affordable Care Act, they know what Medicaid is, and they like it. 

Battles over Medicaid expansion have been fierce, with Democrats leading the expansion drive and Republican leaders, though not always Republican voters, opposing it. Democrats won elections in purple Virginia and in red Louisiana by either advocating for the adoption of the Medicaid expansion or vowing to protect it from rollbacks. 

Medicaid is not just relevant to Democratic candidates. If Republican moderates are ever to regain sway in their party, support for Medicaid may be a route back. 

Some Republican governors have advocated Medicaid expansion in their states even if some have sought to restrict maximum access. If Medicaid expansion provides a way for Democrats to reach Republican voters, it also provides a path the other way. In November 2018, voters in conservative Utah, Nebraska, and Idaho bypassed the opposition of Republican leaders and voted to accept the Medicaid expansion.

The Supreme Court could soon invalidate the Affordable Care Act. But the justices might be a little less likely to cast the Affordable Care Act aside if national political debates highlight the reality that striking down Obamacare would jeopardize Medicaid expansion.  If even Democratic presidential candidates don’t mention Medicaid, that might send a signal that it won’t be actively defended.

Here is a question to ask in the upcoming debates and forums:  

“Whether you support Medicare for All, or a public option, your plan will require difficult congressional action. Medicaid is already in place and popular. What would you do as president to preserve Medicaid expansion under the Affordable Care Act and to encourage its adoption in those states that are not currently on board?”

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Raphael J. Sonenshein is executive director of the Pat Brown Institute at Cal State L.A., Raphael.Sonenshein@calstatela.edu. He wrote this commentary for CalMatters. To read his previous commentary, please click here.