In 2013, Florida Governor Rick Scott said, “While the federal government is committed to paying 100 percent of the cost of new people in Medicaid, I cannot, in good conscience, deny the uninsured access to care,” seemingly acknowledging the obvious truth that Medicaid expansion is the morally and economically sensible thing to do. Within two years he caved to Republican orthodoxy. After the Florida Senate passed Medicaid expansion in 2015, he and the Republican controlled Florida House shut down that effort. There has been little movement on the issue within the state since, leaving approximately 800,000 Floridians trapped in the so called “coverage gap” of individuals too well-off to qualify for Medicaid, but unable to afford private health insurance. A recent CDC report shows that Florida has the third highest uninsured rate in the country, and that the number is increasing.
But now, with Scott term-limited out of the governorship and seeking to replace Democrat Bill Nelson in the United States Senate, the issue is on the table again. Democratic Gubernatorial candidate Gwen Graham has said that, “Medicaid expansion is critical to our state. As governor, I will work with the Legislature to expand health care — and if they won’t, I will veto their priorities until they are willing to listen to the priorities of everyday Floridians.” Andrew Gillum, another Democrat running for Governor, tells us that, “More than a million Floridians literally cannot afford to get sick. If they get sick, they miss work, and they’re not able to pay for the care they need. We need to expand Medicaid in this state so that the most medically-needy amongst us can better care for their families and make sure they’re playing a role in our state’s economy.” Gillum pulls no punches, saying Scott’s refusal to expand Medicaid “is one of his worst moral failings as Governor, and I’ll fix that next year.” Amol Jethwani, a progressive millennial running for the State House District 21 tells us that, “I believe access to clean drinking water, internet, and healthcare are basic human rights in the 21st century. In the Florida House, I will work to bring Medicaid expansion to the state of Florida.” Medicaid expansion is central to his platform and he tells us he discusses it at nearly every campaign event.
Our recent research suggests these assertive and vocal stances are, politically speaking, a wise approach. St. Leo University Polling Institute conducted a poll on Medicaid expansion in May 2015 including data allowing for precise geo-coding. Data for Progress, in collaboration with the local Indivisible groups, used this data to build a robust estimate of support for Medicaid expansion across various demographic groups as well as Florida’s congressional and state legislative districts using multilevel regression and poststratification (MRP), a method becoming increasingly standard in public opinion research, to give us estimates of support for Medicaid expansion for the 2018 electorate.
Medicaid expansion is popular in Florida. With approximately 65 percent support, the policy enjoys higher statewide approval than Rick Scott (approximately 50 percent), Marco Rubio (approximately 55 percent), or Bill Nelson (approximately 58 percent). Support for Medicaid expansion is highest among women, African-Americans, and voters who are low-income (earning less than $30,000 per year)—traditionally Democratic leaning constituencies. But even in traditionally more conservative demographics, the policy enjoys majority support. For instance, roughly 53 percent of white males reported supporting Medicaid expansion.
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Just as importantly for Florida progressives, the policy enjoys greater than 50 percent support in all of Florida’s state legislative and congressional districts. While the variation in the projections is high, the average level of support for Medicaid expansion across all three chambers (Florida Senate, Florida House of Representatives, and Florida’s delegation to the United States House of Representatives) is around 65 percent. Even in Republican controlled districts, levels of support do not fall below 57 percent, or below 59 percent in any Florida House or State Senate district, respectively. The chart below shows the distribution of support, with the height of the bars indicating the share of districts at each level of support (so we can see that roughly 64 percent support in 40 percent of Democratic Senate districts).
These conclusive results are not outliers. In Virginia, another state that has yet to expand Medicaid, Data For Progress and Indivisible—this time in partnership with Civis Analytics—conducted a similar analysis. As was the case in Florida, in no Virginia State Senate or House of Delegates district did two-way support drop beneath the mid-50s. On a nationwide level, Data for Progress used an MRP model and data from the Cooperative Congressional Election Studies 2014 survey to understand support for Medicaid expansion across the country. This research shows that, at that time, the Medicaid expansion had majority support in every state that has not expanded with exception of Wyoming. Even in deep red states like Tennessee, Medicaid expansion carried broad support from the general public. In three deep red states (Idaho, Utah and Nebraska), Medicaid expansion will likely appear on the ballot in 2018, and is currently favored to pass in all of them (even in deep Red Utah, two in three voters support expanding Medicaid).
Why Republicans feel like they can do this
The Florida Medicaid expansion serves as an excellent case study in how Republicans use levers of power throughout federal and state governments to escape democratic accountability. Medicaid Expansion only requires state approval in the first place because the Supreme Court made the expansion optional, in response to a right wing legal challenge to the Affordable Care Act. This decision had not just moral and substantive consequences, but political ones as well. A study by Daniel Hopkins and Kalind Parish finds that the ACA is less popular in states that did not expand Medicaid, particularly among low-income people who would have benefited from the law. In a similar vein, two Ohio State University political scientists find that full Medicaid expansion may have been a decisive factor in the outcome of the 2016 election. Under more democratic circumstances, the Republicans who denied their constituents Medicaid might have faced accountability the way the authors of the ACA did, but in GOP controlled states yet to expand the program, Republican governors and legislators sleep safe knowing that willful, systematic disenfranchisement of minority voters, and gerrymandered districts, shield them from public backlash. .
Democrats can use Medicaid’s overwhelming popularity to retip the scales in favor of Democratic accountability. And, if they play their cards right, their efforts won’t just result in millions of people gaining access to life-saving care, but in political majorities that can make headway on other, slower-burning issues. While Medicaid expansion is effectively on the ballot in Florida this November, so too is a ballot initiative to restore voting rights to 1.5 million people who have been disenfranchised due to past incarceration. A disproportionate number of the 1.5 million are people of color targeted by the criminal justice system, who would stand to benefit from Medicaid expansion. Compounding the direct disenfranchisement problem, a large body of evidence suggests that barriers to voting distort policy in ways that benefit able-bodied people and harm people with disabilities. One study of Medicaid expansion in Alabama found that two-thirds of individuals who fell into the coverage gap (and thus would be covered by Medicaid expansion) were not registered to vote, and many were permanently barred from voting due to Alabama’s strict disenfranchisement laws.
It’s only because of anti-democratic measures like felon disenfranchisement that Republicans were able to reject the Medicaid expansion—denying health care to the very people they disenfranchised. Running on Medicaid expansion will allow Democrats to right these wrongs in reverse.
If they fail, Medicaid will remain unexpanded, voters will remain disenfranchised, and Republicans both in Florida and around the nation will continue to be able to defy public sentiment. Republicans have used control of the judiciary to motivate the GOP base in recent elections. Democrats should do the same with Medicaid, and then leverage their political gains to make headway on related issues like voter suppression and redistricting.
Looking Ahead
Building political majorities on the strength of support for Medicaid expansion might eventually pay further dividends for progressives by awakening pro-Medicaid voters to the power of the judiciary, and motivating Democrats to vote on the basis of judgeships the way many Republicans already do. Right now many Democrats simply don’t understand the importance of the Court. In a new survey, the advocacy group Demand Justice polled 900 Democratic primary voters in eleven states. The survey asked respondents to rate, on a zero to 10 scale, how important it is for the Court to uphold certain issues. The average score for “expanding access to affordable healthcare” was 9.1, and 86 percent of Democrats answered between 8 and 10. Of the 17 issues tested, including money in politics, criminal justice and gun control, none polled as high as healthcare, yet Democrats have done a poor job of highlighting healthcare in the hearing on Trump’s judges. Demand Justice Executive Director Brian Fallon tells us, “Health care is the top issue among an electorate primed to vote Republicans out of Congress, so it is not too surprising that it would also be a top concern for these same voters when it comes to deciding whether someone is fit to serve a lifetime appointment as a federal judge. A number of Trump judges are on record opposing the Affordable Care Act and believing it to be unconstitutional. We should be making that a central argument as we sound the alarm about the types of people Trump is putting on the bench.”
In addition, progressives need to understand the ways that barriers to voting create a bias in policy towards healthy people, as a new report by The Century Foundation shows. Moving forward, progressives need to make voting policies health inclusive. That means ensuring people are registered to vote when interacting with Medicaid offices and healthcare exchanges, something progressives have been slow to aggressively implement.
Recent events in Florida suggest this might be a powerful strategy. One in five Floridians is uninsured, and a report by Institute for Women’s Policy Research found declining mental health and an increase in suicides among women in Florida. These statistics reflect, first and foremost, an unnecessary and tragic policy blunder. But they also represent a political opportunity for Democrats, and an opportunity for progressives to reverse not just the Medicaid expansion injustice, but many others.
John Ray is a data scientist based in Washington, DC and a senior advisor to Data for Progress. He tweets at @johnlray.
Sean McElwee is a co-founder of Data for Progress. He tweets at @SeanMcElwee.
Avery Wendell is a data scientist based in San Francisco and senior adviser to Data for Progress. He tweets at @awendell98.
Jason Ganz is a data analyst based in Denver and senior adviser to Data for Progress. He tweets at @jasnonaz.
