ATLANTA — For the upscale urban audience at a campaign town hall here, it would have been enough for Stacey Abrams to pitch Medicaid expansion as a moral issue — the health-care-as-human-right argument that appeals to progressives everywhere.
Instead, Ms. Abrams, the Democrat in the tossup race for Georgia governor, stuck to the pragmatic line of reasoning she has pushed in making Medicaid expansion a top priority of her campaign: It will help save the state’s struggling rural towns without busting its budget, since the Affordable Care Act requires the federal government to pay 90 percent of the cost.
“Raise your hand if you would say no to someone who said, ‘Give me a dollar and I’ll give you $ 9 back,’” Ms. Abrams said to appreciative laughter at the event earlier this month at Clark Atlanta University, an historically black college. “It is economically false, a falsehood over all, to say we can’t afford to expand Medicaid.”
With health care dominating many a midterm campaign this year, Medicaid expansion has been a major talking point for Democratic gubernatorial candidates in many of the 17 states that have rejected the option, including Florida, Kansas, Oklahoma, Tennessee and Wisconsin. But none have promoted it as forcefully as Ms. Abrams, 44, who would be the nation’s first black female governor if elected and the first Democrat to lead Georgia since 1998.
Her momentum with the issue reflects the experience of Democrats around the country, whose argument that Republicans will not protect access to health care, especially for the sick, seems to be influencing voters more than almost anything, from proposals on immigration and the economy to the battle over Judge Brett M. Kavanaugh’s appointment to the Supreme Court.
Guarding protections for people with pre-existing medical conditions, in particular, is proving a potent closing argument for Democrats and forcing Republican candidates, many of whom voted to repeal the Affordable Care Act last year and support a new lawsuit seeking to invalidate it, on the defensive.
[Make sense of the people, issues and ideas shaping the 2018 elections with our new politics newsletter.]
The federal health care law has grown in popularity since it was enacted in 2010 — reaching a high earlier this year. About half of Americans now say they support it, according to this month’s Kaiser Family Foundation tracking poll.
By framing the expansion of government health coverage for the poor as a smart business move that would save teetering small-town hospitals and create thousands of jobs outside metro Atlanta, Ms. Abrams, an unabashed liberal, is hoping to add enough rural votes to her column to beat Brian Kemp, her Republican opponent, a Trump-style conservative who is against expanding Medicaid.
Polls have consistently shown the two running neck and neck; Mr. Kemp’s main priority for rural areas is expanding access to high-speed internet. He has said that Medicaid expansion “costs too much and fails to deliver,” warning that even the modest state share will take money away from public safety and education.
The fact that Ms. Abrams has put such a polarizing issue front and center in a conservative Deep South state — emphasizing its importance for the rural voters who helped President Trump win Georgia in 2016 — is a reminder of the defensive crouch Republicans find themselves in on health care this election cycle.
In the Kaiser poll this month, 56 percent of people across the 17 holdout states favor expanding Medicaid. An Atlanta Journal-Constitution poll taken in January found that 75 percent of Georgia voters, including 79 percent of independent voters and 51 percent of Republicans, favor expanding the program. That was substantially more than the 57 percent of voters who supported expansion in Georgia in a 2014 poll by the newspaper.
In a sense, Ms. Abrams is following the model of Senator Doug Jones, Democrat of Alabama, who also talked up Medicaid expansion and won an unlikely victory in last year’s special election in part because of strong rural black turnout.
She points to a growing body of research finding that Medicaid expansion has improved access to regular care and medications for low-income people and improved hospitals’ financial performance, especially in rural areas. And she misses no opportunity to point out that eight rural Georgia hospitals have closed over the last decade — more than anywhere but Texas and Tennessee — with many more at risk of doing so, largely because of dwindling populations and insurance payments.
In reality, Ms Abrams could not expand Medicaid “on Day 1,” as she likes to say — and likely not even during her first year in office. The state legislature, which has to agree to it, will almost certainly remain under Republican control. And the leadership will likely remain resistant even though a number of rank-and-file members, especially in rural areas whose hospitals are in jeopardy, could start voicing more support.
But Ms. Abrams, who until last year served as minority leader of the Georgia House of Representatives, insists the legislature will have no choice but to accept Medicaid expansion before long.
“Most of the hospital closures are in Republican districts and they know there has to be a solution,” she said in an interview. “I think there are real political consequences, as well as the moral and physical consequences that have been in place for so long. They can read polls as well as I can.”
Since 2014, the Affordable Care Act has allowed states to provide Medicaid coverage to adults with incomes up to 138 percent of the poverty level, or $ 16,642 for a single person. Currently, adults who aren’t elderly or disabled cannot qualify for Medicaid in Georgia unless they have small children and minute incomes — $ 7,480 a year for a family of three, for example. The state has more uninsured people — nearly 500,000, according to one estimate — who would become eligible for Medicaid under expansion than any but Texas and Florida.
Mr. Kemp, Georgia’s secretary of state, has echoed the outgoing governor, Nathan Deal, also a Republican, in dismissing Medicaid expansion as too expensive.
Ms Abrams puts the eventual cost to Georgia at nearly $ 300 million a year, though offset by savings in charity care and other areas; Republicans say it could be above $ 450 million. For some rural voters, Mr. Kemp’s message resonates more.
“I don’t believe in expanding Medicaid, because the free ride is just overwhelming,” said Debra Mullis, 48, who owns a dog grooming business in Eastman, a city of 5,000 surrounded by farm fields, about 140 miles south of Atlanta. “We’ve got to start putting these people back to work.”
(Research has found that most Medicaid recipients actually do hold part- or full-time jobs.)
Dodge County Hospital, a low-slung complex with 94 beds on the outskirts of town, is one that would benefit from Medicaid expansion. Ten percent of its patients are uninsured, compared with an average of 5 percent for hospitals nationally. If Medicaid began paying for those patients, it could help Eastman avoid the fate of a neighboring town that lost its hospital a decade ago and is still reeling from the blow.
“It’s vital for us,” Kevin Bierschenk, the hospital’s chief executive, said of expanding Medicaid. “We are already taking care of that population; we’re just not getting paid for it.”
Dr. Donald Rosenbaum, the hospital’s sole orthopedic surgeon, is concerned about the cost of expanding Medicaid but hates turning away people who need non-emergency surgeries — anything, he said, beyond broken bones. As he spoke, he was preparing to operate on an uninsured man who had fractured his hand and would be left with a marked deformity, he said, without surgery.
“As a Republican, I want to be financially careful and I don’t want to break the state later down the line,” he said. “But as a physician practicing in a rural area, quite honestly I think we just have to do it. It’s our responsibility to the community.”
Still, Dr. Rosenbaum said he would vote for Mr. Kemp because their positions on most issues aligned.
Ms. Abrams’s argument that Medicaid expansion will save rural hospitals is somewhat muddied by a plan that Republican lawmakers devised to provide a dollar-for-dollar tax credit to any business or individual who donates to a struggling rural hospital. The $ 60 million program provided several dozen hospitals with up to $ 4 million each last year; Dodge County Hospital received $ 1.7 million, more than doubling its profit margin.
Ms. Abrams dismisses the tax credit program as “a Band-Aid,” emphasizing that Medicaid expansion would deliver far more money — most of it from federal, not state coffers.
Mr. Kemp rolled out a health care platform early this month, after the Abrams campaign mocked him for including only seven words about health policy on his website. It includes raising the tax credit program to $ 100 million.
For all the talk about Medicaid, several uninsured residents interviewed in Eastman this month predicted that race would be a more decisive factor for rural voters than health care or any other policy.
“There’s a lot of white people around here that, by God, they just won’t vote for a black person,” said Charles Deloach, 57, a black resident of Eastman who sells produce on a corner across from the hospital and will “most definitely” be voting for Ms. Abrams.
Still, Ms. Abrams’s warnings about hospital closures may have particular resonance here because the hospital in nearby McRae shut down a decade ago, forcing its residents to drive 20 miles to Eastman for care ever since. Miranda Bush, a nurse who used to work there but started at Dodge County Hospital two days after it closed, said the community had not recovered.
“There was between 100 and 200 people who lost jobs,” she said. “It honest to God has been devastating.”
Everything You Need to Know for the Midterm Elections
The midterm elections are around the corner. If you haven’t been keeping up with what’s going on, or have been and are still confused, take a look at our cheat sheet.