As the Trump administration and Republicans in Congress look to scale back Medicaid, many voters and state lawmakers across the country are moving to make it bigger.
On Nov. 7, Maine voters approved a ballot measure to expand Medicaid under the Affordable Care Act. Advocates are looking to follow suit with ballot measures in Utah, Missouri and Idaho in 2018.
Virginia may also have another go at expansion after the Legislature thwarted Gov. Terry McAuliffe鈥檚 attempt to expand Medicaid. Virginia voters elected Democrat Ralph Northam to succeed McAuliffe as governor in January, and Democrats made inroads in the state Legislature, too.
An exit poll of Virginia voters on Election Day found that 39 percent of them听ranked health care听as their No. 1 issue. More than three-quarters of the Virginians in this group voted for Democrats.
础听听from the Urban Institute may shed light on why Medicaid eligibility remains a pressing problem: medical debt. While personal debts related to health care are on the decline overall, they remain far higher in states that didn鈥檛 expand Medicaid.
In some cases, struggles with medical debt can be all-consuming.
Geneva Wilson is in her mid-40s and lives outside of Lowry City, Mo. She has a long history of health problems, including a blood disorder, depression and a painful misalignment of the hip joint called hip dysplasia.
She鈥檚 managed to find some peace living in a small cabin in the woods. She keeps chickens, raises rabbits and has a garden. Her long-term goal is to live off her land by selling what she raises at farmers markets.
Her health has made it hard to keep a job and obtain the insurance that typically comes with it. And Missouri鈥檚 stringent Medicaid requirements 鈥� which exclude nondisabled adults without children听鈥斕齢ave kept her from getting public assistance.
Since graduating from college more than 20 years ago, Wilson has mostly had to pay out-of-pocket for medical care, and that鈥檚 left her with a seemingly endless pile of medical debt.
鈥淎s soon as I get it down a little bit, something happens, and I have to start all over again,鈥� Wilson said.
Right now her medical debt stands at about $3,000, which she pays down by $50 a month. She desperately needs a hip replacement, but she canceled the surgery because, even with a deeply discounted rate from a nearby hospital, she couldn鈥檛 afford it.
鈥淎pproximately $11,000 is what would come out of my pocket to pay for the hip. That鈥檚 my entire pretax wage from last year,鈥� Wilson said. 鈥淪o it鈥檚 kind of on hold, but I don鈥檛 know if I can survive the year without going ahead and trying to get it done.鈥�
For many people like Wilson, medical debt can be nearly as problematic as an illness. In 2015,听听ages 18 to 64 had past-due medical debt, the seventh-highest rate in the country. Kansas, at 27 percent, had the 15th-highest rate. In Maine, which voted to expand Medicaid this week, it was 27.7 percent.
Researchers Aaron Sojourner and Ezra Golberstein of the University of Minnesota studied financial data from 2012 to 2015 for people who would be eligible for Medicaid where it was expanded.
They found that in states that didn鈥檛 expand, the percentage of low-income, nonelderly adults with unpaid medical bills dropped from 47 to 40 percent within three years.
鈥淭he economy improved and maybe other components of the ACA contributed to a 7-percentage-point reduction,鈥� Sojourner says. 鈥淲here they did expand Medicaid, it fell by almost twice as much.鈥�
Those states saw an average drop of 13 percentage points, from 43 to 30 percent.
In Kansas, the rate of medical debt for nonelderly adults fell by 4 percentage points to 27 percent. In Missouri, the rate dropped 4 points to 31 percent, according to the Urban Institute. In Maine, it dropped only 1.4 percentage points from 2012 to 2015.
Medicaid, as opposed to private insurance, is the key, said the Urban Institute鈥檚听, because it requires little out-of-pocket costs.
Even if Medicaid patients need lots of care, they aren鈥檛 on the hook for big out-of-pocket costs in the same way someone with private insurance might be.
鈥淲e would certainly expect their risk to out-of-pocket expenses to be much lower, and ultimately the risk of unpaid bills to ultimately be also lower,鈥� Caswell said.
But Medicaid鈥檚 debt-reducing advantages over private insurance could disappear under the leadership of the Trump administration.
Shortly after Seema Verma was confirmed as the administrator for the Centers for Medicare & Medicaid Services, she and Tom Price, then head of the Department of Health and Human Services, sent听听to the governors outlining their plans for Medicaid.
The letter encouraged states to consider measures that would make their Medicaid programs operate more like commercial health insurance, including introducing premiums and copayments for emergency room visits.
Verma said that by giving recipients more 鈥渟kin in the game,鈥� they will take more responsibility for the cost of care and save the program money.
Republican proposals in Congress to repeal and replace the Affordable Care Act would have eliminated or limited Medicaid expansion. And that would have affected the last few years鈥� downward trend in medical debt.
鈥淎nything that reduces access to Medicaid most likely would have the reverse effect of what we鈥檙e seeing in our paper,鈥� Caswell said. 鈥淩educed access to Medicaid would likely increase exposure to medical out-of-pocket spending and ultimately unpaid medical bills.鈥�
As Geneva Wilson tends to her chickens, she said, she tries not to think too much about her medical debt or how she鈥檒l pay for that hip replacement.
鈥淚t鈥檚 going to the point where, if I were to go shopping at Walmart, I would have to get one of the carts you drive because I can鈥檛 manage,鈥� she said.
Wilson has already sold her jewelry, some furniture and a wood stove to pay down her debts. Now there鈥檚 not much left to sell except her cabin and her land.
鈥淧robably the homestead and garden that I want, that I鈥檝e been wanting and trying to work for, I don鈥檛 think they are a viable dream either,鈥� Wilson said. 鈥淚t鈥檚 hard losing your dreams.鈥�
This story is part of a partnership that includes , and Kaiser Health News.