In Health Bill’s Defeat, Medicaid Comes of Age

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…

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