Democratic presidential candidates should focus on the issue that matters to California voters: health care, specifically Medicaid

By Raphael J. Sonenshein, Special to CalMatters

In this Tuesday’s presidential primary, Democratic voters will be overwhelmingly focused on defeating President Donald Trump. 

Policy issues have taken a back seat. But to the extent that any other issue persists, it is health care policy. 

While Democrats have long held an immense advantage over Republicans on this issue, the Democratic presidential candidates are fighting an internal battle over what the party’s policy should be.  

Other than who is most likely to defeat Trump, health care is the main dividing line. In fact, candidate positions on health care are being weighed as a factor in electability.

At this point in the campaign, the left and the center-left candidates are promoting appealing, competing reforms, Medicare for All and the public option, each of which will require congressional passage.  

There continues to be a missing piece in this intra party debate: Medicaid. And it has particular resonance in California.

The Affordable Care Act expanded Medicaid to states. Thirty-seven states have now accepted the Medicaid expansion. California jumped into the Affordable Care Act and the Medicaid expansion with both feet. 

California has knocked its uninsured rate down from 18% to 7% with a major contribution from the Medicaid expansion. According to a 2017 state report, 3,729,175 Californians were enrolled in Medi-Cal as a result of the Affordable Care Act. L.A. County alone added more than 1.1 million residents.

While campaigning here, candidates should consider that of the state’s nearly 40 million residents, 13.2 million are enrolled in Medi-Cal, California’s version of Medicaid. Half of the state’s children are enrolled. 

According to the California Budget & Policy Center, 40% of L.A. County residents are covered by Medi-Cal, as the state’s Medicaid program is called. In Fresno County, it’s 49.9%, and in Kern County, it is 45.1%. These are counties, outside the big metro areas, where candidates hope to make a dent.

Both sides in this intra party debate are ignoring the health care lessons of the 2018 midterm elections. The health care battles in the states are all about the Medicaid expansion. 

Democratic candidates in 2018, on the left and in the left-center, did not spend much time talking about new healthcare legislation. And they won.  

Democratic governors in Virginia and Louisiana owe their victories in part to their advocacy of Medicaid expansion in their states. Perhaps this is one case where state-level politicians knew something the big timers don’t about the current trenches in the political battle over health care.

The weight of state politics is bending toward expansion. There is genuine potential to cross party lines.  

In 2018, voters in three red states passed ballot measures to accept the expansion. Holdout states include Georgia and Texas. 

  • Expansion in Georgia would cover 500,000 currently uninsured people.  
  • Expansion in Texas would add 1.1 million according to the Kaiser Family Foundation.  

Just there, that would be 1.6 million people gaining basic health care who don’t have it now.  If Democrats want to make these states competitive someday for Democrats, openly advocating this improvement could make a big difference.

Voters understand the Medicaid expansion. Yet the word Medicaid has been nearly absent from the presidential debates. 

President Trump has been free to talk about massive cuts to Medicaid, an immensely popular program, without much pushback or even mention from the candidates.

Here’s a slogan: along with Medicare for All, or Medicare for all who want it, how about “And Medicaid for all who need it?” 

Republican strategists understand the danger of being on the wrong side of the Medicaid expansion, and how getting close to health care for all would support broader reforms.  

That’s why the Trump administration has urged the Supreme Court to hold off until after the election to rule on its bid to eliminate the Affordable Care Act, which would take the Medicaid expansion with it.  

As they speak to California Democrats and independents, maybe Democratic presidential candidates should join the present battle as the best path to future visions.


Raphael J. Sonenshein is executive director of the Pat Brown Institute at Cal State L.A., [email protected] He wrote this commentary for CalMatters. To read his previous commentary, please click here, and here.

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