By the 1980s and ’90s, health insurance was becoming prohibitively costly, and wages were starting to stagnate. Employer-based health insurance was eroding. States led by Republicans as well as Democrats began to expand their Medicaid programs.
“What people began to accept, including Republicans, was that the assumption that you could afford health insurance if you were an able-bodied adult was not true,” said Colleen M. Grogan, a professor at the School of Social Service Administration at the University of Chicago, who has written extensively on health care. “You could be working and still not afford health insurance.”
In 1996, Mr. Clinton expanded Medicaid to cover more working families as part of his welfare overhaul. Campaigning for re-election that year, he depicted Medicaid as a middle-class program, telling audiences it was helping their grandparents.
“He is the first Democrat to start calling Medicaid one of ‘our programs,’” said Professor Morone of Brown. “There was a sense that Medicaid had sort of grown up as an entitlement.”
The expansion of Medicaid in the Children’s Health Insurance Program, passed with Republican sponsorship in 1997, set the stage for the sweeping expansions of the Affordable Care Act 13 years later.
But politics during Mr. Obama’s presidency had become highly polarized. While earlier expansions of Medicaid had sometimes been bipartisan, the A.C.A. passed without a single Republican vote in Congress. The Tea Party had risen in opposition to the legislation, and later helped elect many of those who now form the conservative Freedom Caucus.
Gradually, though, Republican-led states have adopted the expansion. And now that the law known as Obamacare has survived the effort to repeal it, more states may choose to expand Medicaid. In Maine, voters will decide this fall whether to do so, and in Kansas, the Legislature has all but approved an expansion, although Gov. Sam Brownback could veto it.
Last week, despite their desire to repeal Mr. Obama’s biggest domestic legacy, some Republicans recognized that any bill that would lead to such drastic cuts in Medicaid would simply hurt too many of their constituents.
In Ashland, Va., Medicaid made it possible for Kim Goodloe and her husband, Tom, to start a small company making metal parts for semiconductors and medical devices after the birth of twin boys with tuberous sclerosis 27 years ago. The genetic disorder causes tumors in vital organs, leading to frequent seizures, and Mrs. Goodloe had quit her job to take care of the boys when they were 4 — Medicaid did not cover services for them back then. But now, Medicaid provides a home aide for Matthew, who is incontinent and nonverbal, suffers daily seizures and needs help walking.
For the other twin, Christopher, who is less severely developmentally disabled, Medicaid provided a job coach, helping him to work at their company and earn enough money that he now pays taxes.
The Goodloes have private insurance, but it is not required to pay for the twins’ services, she said. With Virginia facing such steep cuts to its federal Medicaid payments, Mrs. Goodloe worried about losing the home health aide. They would have had to downsize the business, which employs 30 people.
“Even within my own family, when you say ‘Medicaid’ it comes with some, ‘Those people don’t want to work.’ They believe there’s a lot of fraud, there’s people that don’t deserve it.”
“But then,” she said, “They’ll say, ‘How could they take it away from Matthew?’”