GOODING IS A small town in Idaho, one of America’s most conservative states. It is the sort of place where a campaigner may encounter a man butchering an elk on the dining-room table. It is not a place where you would expect to find much support for a ballot initiative that would expand Medicaid, the government health-insurance programme for the poor. Medicaid expansion, after all, is a pillar of the Affordable Care Act, as Obamacare is formally known. Yet Molly Page, an organiser, gets a surprisingly kind hearing from local people.
One woman turns out to be a fervent supporter of President Donald Trump who fears a deep-state conspiracy to remove him from office. She nonetheless supports the ballot measure. Her two adult sons are uninsured, including one with alcoholism and epilepsy who skipped treatment because “it’s too damned expensive”. Even the elk-butcherer, a few doors away, hears Ms Page out. Polls suggest that a comfortable majority of Idaho’s voters will approve Medicaid expansion on November 6th. Voters in Utah, Nebraska and Montana will probably do the same.
The Affordable Care Act extended eligibility for Medicaid from the very poor to the slightly less poor—from 43% of the federal poverty line (an income of less than $8,935 a year for a family of three) to 138%. But in 2012 the Supreme Court ruled that states could decide whether to allow this. Even though the federal government would pick up 90% of the bill, most states led by Republicans opted out.
In those states, a “coverage gap” emerged. Millions of working people earned too much to qualify for Medicaid but too little to qualify for tax credits on Obamacare’s health-insurance exchanges. For a working family of three people, an annual income between $9,000 and $21,000 would probably result in no health insurance. The ballot initiatives aim to cover people in this position.
A’lana Amy Marmel, a waitress in Idaho Falls and a single mother, is one such person. Though her children are covered by government insurance, she is not. She is still working to pay off a $500 doctor’s bill incurred years ago. “It would mean a world of less worry on my shoulders if I had access to meaningful health care,” she says.
Only 7.5% of non-elderly adults lack insurance in states that expanded Medicaid, compared with 16.1% in states that did not. And expansion would have other good effects. In Oregon, Medicaid was made available to people who were drawn in a lottery. Compared with a control group, the lucky recipients had less financial strain and significantly lower rates of depression. Researchers also found that those who got coverage sought more health services, both preventive coverage and emergency care (which increased by a remarkable 40%).
The expansion would be a boon for rural hospitals, which treat the uninsured but are seldom paid for it. In rural Idaho, 28% of poor adults lack insurance. “In the Oregon health experiment, we estimate that 60 cents of every dollar in additional Medicaid spending actually is a transfer to the providers of uncompensated care,” says Amy Finkelstein, a health economist at MIT. Greg Moody, who directed Medicaid expansion in Ohio after the Republican John Kasich broke with party orthodoxy, notes that the change halved the uninsured rate and brought funding to fight opioid addiction.
Opponents of Medicaid expansion see this as a vulnerability. Wayne Hoffman, president of the Idaho Freedom Foundation, a libertarian think-tank, denounces the initiative as a project of big hospitals and unions. The Idaho Hospital Association has indeed given $150,000 to support it; the Fairness Project, a non-profit group funded by a California health-workers union, has spent millions backing the effort. “We’re also reminding people that it is part of Obamacare, which is still very much hated in Idaho,” says Mr Hoffman. But memories of Mr Obama are fading.