Republicans who think the American public is clamoring to repeal or roll back the Affordable Care Act have another think coming.

Voters in Maine overwhelmingly enacted Medicaid expansion for their state Tuesday, overturning a string of five successive vetoes by their right-wing governor, Paul LePage. The vote was roughly 60%-40%. Maine thus becomes the 33rd state (including the District of Columbia) to expand Medicaid under the Affordable Care Act, the first to do so during the Trump administration, and the first to do so by ballot initiative.

Expect more of the same in other states where the Republican political establishment has blocked expansion, including Utah and Kansas. LePage, by the way, has said he’ll refuse to implement the policy mandated by Maine’s voters, but he’s sure to face a fight over his position.

The Maine result, which will bring health coverage to an estimated 80,000 residents, has other national reverberations. The state’s senior Sen. Susan Collins, a Republican, has been a steadfast opponent of GOP efforts to repeal the ACA in Congress. She also has expressed distaste for the House GOP’s idea to fold an Obamacare rollback into its tax cut measure. The vote back home will only strengthen her resolve; the chance she will change her mind now has to be counted at less than zero.


We will not just accept the hollow victory of numbers covered. Medicaid Administrator Seema Verma

In Virginia, Ralph Northam was elected to succeed his fellow Democrat Terry McAuliffe as governor, which may mean a renewed push to expand Medicaid there. Northam will be helped by the apparent flip of the state’s lower legislative chamber, the House of Delegates, from Republican to Democrat (four key seats are too close to call and require a recount). The state Senate remains narrowly Republican and won’t be subject to election until 2019, but its GOP members may want to take a close look at their opposition to Medicaid if expansion comes before them again.

The election results suggest that the public strongly favors Obamacare in general and Medicaid expansion in particular. What’s fascinating about that is that they came the very day that Trump’s Medicaid administrator, Seema Verma, unveiled a new attack on Medicaid expansion that would almost certainly result in fewer enrollees.

The statewide ballot measures were not remotely close. Medicaid expansion passed by almost 20 points. But Gov. LePage is threatening to block the expansion.

Map: https://t.co/HD1raOofLK

Story: https://t.co/0mcEko3e0c — Portland Press Herald (@PressHerald) November 8, 2017


Verma’s attack, which came in a speech to the National Assn. of Medicaid Directors on Tuesday, was backed by some very misleading statistics and suspect assertions. They’re worth examining in detail.

Verma’s general theme was that simply enrolling more people in Medicaid wouldn’t guarantee they’d get better care, and might even undermine the care provided to existing enrollees. Of the successful expansion of Medicaid rolls under the ACA, she said, “We will not just accept the hollow victory of numbers covered.”

This is a remark of almost medieval stupidity. All the evidence available indicates that having coverage under Medicaid produces better health, including mental health, than the lack of coverage, as well as improved family finances. It’s no “hollow victory” by any standard.

Verma depicted Medicaid as rife with “problems with access, problems with quality, and problems with program integrity.” She observed that “more than 1/3 of doctors won’t even see Medicaid patients.”


A couple of points here. First, the evidence shows that Medicaid patients’ access to care, the quality of their care and their satisfaction with their care are commensurate with that of patients with employer-paid coverage, and hugely superior to the experience of people without insurance. It’s true that about 30% of doctors won’t take Medicaid patients, but that means that 70% do. The reason for the minority’s resistance, moreover, is that Medicaid’s reimbursement rates are very low. To correct that, Verma’s agency should raise the reimbursement rates; increased acceptance by doctors would surely follow.

Verma depicted Medicaid expansion as a drain on state budgets. But she used extremely deceptive statistics. She remarked that Medicaid has grown to “consume” some 29% of total state spending, diverting state resources from other areas such as education and economic development.” What she didn’t say is that more than half of that spending is provided by the federal government. In other words, most of it isn’t coming from state funds for those other purposes. The truth was staring Verma in the face: The figures come out of a report by the National Assn. of State Budget Officers that she cited in a footnote to her own remarks.

What Seema Verma doesn’t know will hurt you: Medicaid services are as good as those provided by private insurance in these major metrics, and far better than being uninsured. (Kaiser Family Foundation )

Indeed, the Medicaid expansion coverage is more than 90% funded by the federal government. That’s a remarkably good deal, and one that has been turned down by 19 states whose political leaders are addled by anti-Medicaid ideology. The voters in Maine plainly understand how the math works to their advantage.


The thrust of Verma’s attack on Medicaid expansion came directly from the right-wing anti-Obamacare playbook. Its theme is that Medicaid expansion added “able-bodied” people to the program’s rolls, ostensibly at the expense of the “seniors in need, pregnant mothers, children and people with disabilities” for whom the program was created. Medicaid expansion, it’s true, added childless adults to these rolls, but nothing about that undermined the care of the other beneficiaries.

In any case, the “able-bodied” slam is merely a variation of the “undeserving poor” theme that has been cherished by conservatives for more than half a century. It was the same slam retailed by right-wing pundit Ben Domenech on CBS’s “Face the Nation” in June, when he backed it up with an utterly bogus statistic (without any pushback by the news program’s moderator, John Dickerson).

Verma shed crocodile tears over the fact that the federal match rate of Medicaid expansion costs is more than 90%, compared to the national average of about 63% for traditional Medicaid. “If the match rate is a reflection of the value we place on caring for our neediest citizens, this is backwards,” she told her audience.

One can’t argue with that. But here’s a solution Verma apparently hasn’t considered: Cover all Medicaid spending at more than 90%. That would show that we value caring for our neediest citizens very highly indeed.


What is Verma’s answer? It’s to place more obstacles in the way of Americans seeking coverage under Medicaid. She signaled that the Trump administration will be much more accommodating to states asking to impose work requirements and other mandates on Medicaid applicants. Typically for the Trump administration, she concealed this intention behind the phrase “community engagement requirements.”

Why Medicaid work requirements are useless: Most recipients are already working, and most of those who aren’t have good reasons. (Kaiser Family Foundation )

Let’s be clear: As administrator of the Centers for Medicare and Medicaid Services, it’s not Verma’s job to manage the labor force participation rate, the figure she cited to justify work requirements for Medicaid. Her job is to maximize coverage, not place roadblocks in the way of enrollment. For her to advocate work requirements for Medicaid is nothing short of a dereliction of duty.

Not only that, it’s a reflection of profound ignorance about the Medicaid population. The fact is that most people eligible for expanded Medicaid already are working. Most of the rest can’t work even if they want to—29% are caring for family members at home, 18% are going to school, 17% are ill or disabled, 10% are retired and 20% can’t find work. Verma’s chatter about “community engagement” is window dressing for her real intention, which is to cut people out of Medicaid.


Verma’s speech indicates that the Trump administration isn’t letting up one bit in its campaign to undermine the Affordable Care Act any way it can. But Tuesday’s election results suggest that the ground is shifting under its feet. Americans like having insurance coverage, and increasingly they see resistance to Medicaid expansion negatively. Trump should take note.

Keep up to date with Michael Hiltzik. Follow @hiltzikm on Twitter, see his Facebook page, or email michael.hiltzik@latimes.com.

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