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Medicaid adjustment

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Last week I had coffee with an Idaho Democrat who ran for the legislature eight years ago. He recalled that back then, soon after passage of the Affordable Care Act – Obamacare – he was warned by his party’s advisors not to raise the subject when out campaigning.

And that was good campaign advice, he said, finding that attitudes on the new law in many places were so harshly negative that he wouldn’t get a hearing.

Skip forward to 2018 and what is in many ways the top item – the one that will surely receive most national attention whatever the result – on the Idaho ballot: Proposition 2, the initiative to expand Medicaid.

There are no election results out yet. But this measure, which would bring in Idaho a key element of Obamacare which has been stoutly and steadily blocked by the state’s majority-elected officials for eight years, looks poised for passage.

Given Idaho’s history with the ACA, and that of the officials its voters have routinely re-elected over these years, the fact that the initiative even reached the ballot is remarkable. Idaho’s insurance marketplace (which has worked effectively) came into place only after a lot of angst. Skeptics had to wonder, when the activists started their extensive qualification efforts, whether they even would come close to a vote, not just because Idaho’s ballot-access rules have been ratcheted so tight but also because the state just seemed so reflexively anti-ACA.

But ballot status was gained, with a lot of effort but also as advocates found a lot of local support. Polling has shown strong support for the measure. Endorsements have come from some startling places. (Most interesting to me still is the sheriffs’ association, but notable backing has continued to emerge even last week.) The pro side financially has vastly outraised and outspent the opposition. People who a few years ago would have taken care to avoid the whole subject now sound confident it will pass, and pass easily.

In theory, this measure could have been proposed for the ballot in 2010 or 2012, but it wasn’t, and probably few people then would have expected it either could reach the ballot or pass if it did.

What changed?

There’s a significant question, because something evidently has. If voters do decisively reject Proposition 2 next month, that maybe a sign that not much is new. But if voters in Idaho (and possibly Nebraska and Utah as well, both similarly red states) approve it, then time has come for some serious thinking.

Maybe part of it was watching the Idaho insurance marketplace come into being and discovering that the health care world hadn’t collapsed, and did improve for a lot of people. Taken as individual pieces, the provisions of the Affordable Care Act, such as helping people with pre-existing conditions, mostly have been highly popular across most of the country. (The main consistent exception was the insurance purchase mandate.)

Another aspect may be the experience of other states where the reaction to Medicaid expansion has been positive. Except for Wyoming, every state surrounding both Idaho and Utah (nearly all of the western states) have approved the expansion, and none are reporting any big problems.

The costs of not expanding Medicaid have become ever clearer too. The support Idaho sheriffs have delivered for the proposal should be a powerful message, and in many smaller counties it may be. So may the message that expanding Medicaid could be just the financial tonic needed to keep many small rural hospitals, many of them struggling, afloat.

The results in another week or so will tell a lot. But Idahoans do seem to be looking at health care differently than they did only a few years ago, and that may carry a load of meaning in years to come.
 

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