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How to improve the health care of 825,000 people? By ballot

"My participation helps move the needle forward."

Credit: Hero Images
Credit: Hero Images

Big things are happening for more than 800,000 million people nationwide.

Effective January 1st, roughly 400,000 people will have Medicaid insurance in Virginia; in New Jersey, another 275,000 people will see their Obamacare premiums reduce next year; and 150,000 undocumented Californians could soon have health coverage for the first time.

And political participation made it all possible.

Turnout for Virginia’s gubernatorial race last November was the highest in 20 years, and many were fired up by health care. Voters elected Democrats who ran on expanding Medicaid under the Affordable Care Act (ACA), and those lawmakers along with rogue Republicans made it happen six months later, sending a budget with expansion to Gov. Ralph Northam (D) Wednesday evening — a scenario that seemed implausible given the last five years of Republican obstructionism.

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“A lot of people may look at the election on the national level, the 2016 election, and think ‘politics is really fraught and the thing that most people want isn’t necessarily the thing that they’re going to get,'” said Dr. Jamila Michener, assistant professor of government at Cornell University. “What we have seen unfold in Virginia these last few days really provides us with a different kind of perspective. It shows us one set of conditions under which voters can make decisions that matter.”

New Jersey voters picked a Democratic governor last November, after eight years with Gov. Chris Christie (R). While residents cared more about corruption when they cast their votes, they also got progressive health policy. In his first bill signing, Gov. Phil Murphy (D) restored family planning funds for Planned Parenthood. And this week, he signed two measures to shore up the ACA marketplace, creating the first state individual mandate since the Trump administration repealed it. Now, New Jersey residents will have to pay a tax penalty for not having insurance — as was previously required — and that money will be used to lower premiums offered on the marketplace.

“It’s a situation where you feel like you have a say,” said Carolina Gamero with California Immigrant Policy Center, constituent-based immigrant rights organization, of local elections. “My participation helps move the needle forward.” 

California progressives, who’ve worked hard to take control of the state party’s agenda, are also reaping the rewards from advocacy efforts. The California Legislature advanced two bills on Wednesday that would remove Medicaid eligibility based on immigration status for people under 26 and 65 or older. The two parallel legislative proposals, dubbed Health4All Adults, build on the success of Health4All Kids, 2015 legislation that provided coverage to 218,000 undocumented children. Health4All Adults is the latest ask from advocates because the main objective is universal coverage.

This is why the primary next week in California is critical. It becomes a question of whether local candidate’s health plan includes immigrants, a community often left out of the conversation.

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“We need to make sure our leaders moving forward are invested that everyone has coverage regardless of immigration status,” Gamero told ThinkProgress. 

The week’s events have solidified the importance of state house races and their influence over people’s health care. Health care is among the top issues voters want to hear about ahead of the 2018 midterms. Democrats running for federal office know this and so are focusing on it in their campaign ads, running more than 26,000 ads on the subject, according to a USA TODAY analysis. But in addition to 35 Senate seats and all 435 House seats up for election in November, 87 of the 99 state legislative chambers are also holding general elections. This means 6,069 seats or roughly 82 percent of the total state legislative seats are up nationwide. There will also be gubernatorial elections in 36 states and 3 territories.

These races become especially critical at a time when state legislatures and governors are now tasked with defending the ACA and Medicaid, as there’s little to no political will on Capitol Hill. Connecticut lawmakers, for example, tried to impose a state individual mandate, but failed to garner enough support to get out of committee. States could also improve upon current access, as is the case in California. And if California is also ever going to move on a single-payer bill, a supermajority vote is necessary in both the state Senate and Assembly, as to overcome state constitutional hurdles.

“Right now it many cases, we are in survival mode,” said Michener, author of Fragmented Democracy. “Let’s try to protect as many vulnerable populations that we can to the greatest extent that we can in a political environment that is otherwise  — I’ll be honest here — hostile to these populations.”

But this survival mode sometimes compels local lawmakers to compromise certain group’s access to health care — and this undoubtedly will influence future elections. Virginia, for example, was only able to expand health care to 400,000 people because they added work requirements, premiums, and copays for the many of the newly eligible. Conditioning Medicaid expansion on work requirements has become a fact many have been forced to grapple with, as it’s said to be the only way to prop up the ACA under Republicans.

“We figure out state-by-state what the feasible political plan is and we do that, and that’s how we help as many vulnerable people as possible — that is the practical perspective — and I am not opposed to it — but it is in the end shortsighted,”   said Michener.

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“In the places where people are really engaged, even if they are places like Virginia or like Utah that otherwise you might think of as politically hospitable to something like Medicaid expansion but in those places it happens and so now we have it and it happened because of the engagement and involvement of voters and other citizens. But then by virtue that it happened in these specific ways — that have punitive elements — we are making it less likely in the future that we are going to see that level of engagement from the people that are most affected.”

The idea is: why would you be politically motivated if you’re alienated? But these are the trade-offs when health access is contingent on zip code.