Texas Rep. Beto O’Rourke’s focus on Obamacare has raised eyebrows in his deep-red state. | Tom Fox-Pool/Getty Images Elections Will Beto’s bet on Medicaid expansion pay off? Democrats’ past attempts to campaign on that issue fell flat, but there are signs this year might be different.

Beto O'Rourke has staked his long-shot campaign to beat Sen. Ted Cruz on the idea that Obamacare should be even bigger in Texas — a state that has done more than any other to try to destroy the landmark health care law.

It just might be working.


O’Rourke is closing in on the Republican senator in multiple polls, a shocking development in a state that hasn’t sent a Democrat to the Senate since 1993.

Still, O’Rourke’s focus on Obamacare — he talks about expanding Medicaid at every campaign event — has raised eyebrows in this deep-red state. After all, Democrats’ past attempts to campaign on the health law’s Medicaid expansion fell flat, largely because the Texans with the most at stake didn’t show up to vote. Four years ago, Wendy Davis called repeatedly for Medicaid expansion and lost the governor’s race by more than 20 points.

Cruz, for his part, is campaigning mostly on red-meat, culture war issues like guns and kneeling NFL players, but he’s also sticking with the promise to repeal Obamacare that swept him into office in 2012. As for Medicaid expansion, he tells POLITICO it “would hurt millions of Texans.”

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Texas political experts are divided about whether O’Rourke and his health care-focused campaign can overcome the state’s abysmal voter turnout and low public awareness about health care and how it works.

“The populations who would benefit most from Medicaid expansion, and are the most supportive of it, are people in poverty and people of color,” said Gabriel Sanchez, a principal at the polling firm Latino Decisions and the Robert Wood Johnson Foundation Center for Health Policy. “But those are the groups that tend to have the lowest turnout, particularly in an off-year, non-presidential election. And there are not really any signs of it changing this year.”

Democrats point to signs 2018 might be different — but just how different remains to be seen. Popular interest in Medicaid expansion has been resonating during this campaign cycle not just in Texas, but in other red states such as Idaho, Nebraska and Utah, giving candidates like O’Rourke hope they might ride a health care-fueled blue wave to victory.

Recent polls also show a strong majority of Texans side with O’Rourke when it comes to Medicaid. A September survey by the Texas Medical Center found that 60 percent of Texans support expanding Medicaid, including 57 percent of independents and 40 percent of Republicans. A similar survey in June by Houston-based Episcopal Health Foundation and the Kaiser Family Foundation found 64 percent in favor.

Republicans suggest such poll results are less than meet the eye: James Dickey, chairman of the Texas Republican Party, told POLITICO that Medicaid expansion polls well only because people generally want their neighbors to have health coverage and aren’t asked to evaluate all possible options.

Rather than the “Democrat approach of increasing the number of bureaucrats between patients and doctors,” he said, “a market-based health system would benefit folks the most. Competition drives down cost and drives up quality. This is the solution Republican leaders seek to deliver for Texans and exactly why Republicans will be reelected in November.”

That message may be less convincing this campaign season, though, since Republicans have failed to deliver that reform even after they seized control of every lever of government power in both Austin and Washington, D.C. Polls indicate most voters fault Republicans for the nation’s current health care woes and trust Democrats more on setting health policy.

The threats to the Affordable Care Act’s protections may also feel more immediate to Texans than most Americans. A lawsuit filed this year by Texas’ attorney general aims to strike down the most popular piece of Obamacare — protections for people with preexisting conditions. And Cruz, who is perhaps best-known for triggering a government shutdown over Obamacare funding in 2013, is still vowing to work for its repeal.

The Texas Democratic Party’s Tariq Thowfeek told POLITICO that O’Rourke is running a different kind of campaign than those of his predecessors, venturing out of the state’s major urban centers into the small towns and rural counties the party has written off in past cycles and addressing people’s problems in plain language.

“He’s visiting places that don't normally vote Democratic, and instead of talking about ‘Obamacare’ or the Affordable Care Act, there has been an effort to talk about it in a more human way,” Thowfeek said. “He’s saying things like, ‘We all should agree that you shouldn’t have to break the bank going to the doctor,’ or ‘You shouldn’t have to drive 100 miles to get to a hospital,’ or ‘If you have a kid with asthma, her coverage is on the line right now, because it’s a preexisting condition.’”

Other factors could also work in O’Rourke’s favor.

Support for expanding Medicaid is particularly high among Latino voters — a demographic that has not traditionally voted in large numbers and that O’Rourke needs to turn out for him to win. A national poll of Latino voters provided exclusively to POLITICO by Unidos and Hart Research found that 70 percent believe the government should play a “major role” in making sure “every American has health insurance,” and 82 percent view Medicaid favorably.

“When we talk about ensuring every woman, child and man can see a doctor, afford their prescriptions, and get the health care they need to live to their full potential, it starts with expanding Medicaid in the least insured state,” O’Rourke’s communications director Chris Evans told POLITICO. “Beto has talked about health care everywhere we go because it's the No. 1 issue Texans are asking about at the hundreds of town halls we've held across the state.”

Evans also noted that the campaign has made the issue a centerpiece of its ads, including radio ads airing statewide in English and Spanish.

Whether the Texans who hear and respond to those ads actually cast ballots is the big question, said Anne Dunkelberg, program director of the Health and Wellness Team at the Austin-based progressive Center for Public Policy Priorities.

“It’s been the case for quite some time that most Texans support expanded Medicaid coverage,” she said. “But one of the big challenges we have is elected officials ignoring the polling because they know many won’t show up to vote.”

Another factor preserving the status quo is widespread confusion and misinformation about how Texans fare relative to other states’ residents when it comes to health care, said Dunkelberg, who formerly worked in the state Medicaid Director’s Office. This summer, a Kaiser Family Foundation survey found that less than a third of Texans are aware their state has the worst uninsurance rate in the country.

“Those who are uninsured themselves are no more likely than their insured counterparts to be aware of this fact,” the survey concluded, noting that nearly 20 percent mistakenly believed the state is doing better than most on this front.

“That was kind of shocking,” Dunkelberg said.

For Sanchez at Latino Decisions, that lack of awareness feeds uninformed voting, if not apathy.

“For most folks, health policy is so complicated,’” he said. “[President Donald] Trump has been talking nonstop about killing it, so many people think Obamacare is no longer in place. There are a lot of moderate Republicans in Texas, many of them Latinos, who would benefit from expansion. But because they don’t understand it, they just vote by party.”

