Voters help strengthen Obamacare’s hold in U.S.

President Trump wants the Supreme Court to clear the decks for his long-promised Obamacare replacement, but his predecessor’s law is solidifying its place in the U.S., with two more states opting to expand their Medicaid rolls under the 2010 program.

Voters in Oklahoma and Missouri ignored Republican opposition and agreed to accept federal funding for the expansion in this election cycle, thrilling Democrats and leaving only a dozen states that have refused to accept Washington’s offer to pay 90% of the costs of augmenting the insurance program for the poor.

Fights over the interlocking gears of the Affordable Care Act’s web exchanges, coverage rules and mandates dominated President Obama’s tenure and Mr. Trump’s piecemeal attempts to dismantle the program.

Yet expanding Medicaid to those making slightly above the federal poverty level has become the quiet workhorse of the program, extending insurance to millions of people and boosting struggling rural hospitals, even as Republicans warn that their share of the costs is unsustainable.

“While the exchanges have wrecked the individual health market — only the poorest with the biggest subsidies are benefiting while those not subsidized can’t afford the outrageous premiums — the large majority of those gaining coverage have done so through Medicaid,” said Robert Laszewski, a health policy consultant in Alexandria, Virginia.

Under Obamacare, the federal government said any state that expanded coverage to those making up to 138% of the federal poverty level would not have to pay for any of it from 2014 to 2016. Washington’s share phased down through this year. States now must pick up 10% of the cost.

The federal poverty level is an annual income of $12,760 for one person and $26,200 for a household of four.

The Supreme Court made the expansion optional, but many governors — even Republicans such as John Kasich of Ohio — said the federal offer was too good to pass up. Holdout Republicans say it is still too costly despite Washington’s largesse, though grassroots activists in several states are taking the decision out of their hands.

Voters in deep-red Oklahoma narrowly opted to expand the state’s Medicaid program a month ago. Missouri voters approved the expansion 53% to 47% on Tuesday, clearing the way for more than 200,000 adults in the state to gain coverage.

Similar voter drives have expanded the program in Maine, Nebraska, Idaho and Utah.

“The Medicaid expansion has worked well in the large number of states that have done it. Claims by opponents that it would bankrupt the states and that the feds would not keep their promises to fund the vast majority of the expansion have not come to pass,” Mr. Laszewski said.

The push to expand the reach of Obamacare is at loggerheads with a state-driven lawsuit to invalidate Mr. Obama’s program entirely.

Texas Attorney General Ken Paxton and other Republican plaintiffs argue that because the Supreme Court, with Chief Justice John G. Roberts Jr. as the swing vote, determined in 2012 that the Affordable Care Act’s individual mandate is central to its constitutionality, Congress invalidated the law by zeroing out the penalty for lacking insurance in the 2017 Republican tax overhaul.

“The entire ACA thus must fall with the individual mandate,” Solicitor General Noel J. Francisco said in a brief from the Trump administration in support of the state plaintiffs.

Mr. Trump is cheering on the lawsuit because he believes it would clear the way for the health plan he promised voters in 2016.

“What we want to do is terminate it and give great health care. And we’ll have great health care, including preexisting conditions,” he said during a White House event in May.

He is using the run-up to the November election to tease a “health plan” through executive order, but he hasn’t offered details or an exact time for its release.

Some health care experts say the Texas lawsuit is a long shot and that the push to expand Medicaid in quarters of the country underscores a lack of enthusiasm for the court challenge among mainstream Republicans.

Nearly 11 million people held private insurance through the Obamacare exchanges as of March, according to federal statistics.

Meanwhile, roughly 12.5 million became eligible for Medicaid coverage through the state expansions, according to the Kaiser Family Foundation. That number is set to grow as more states expand.

“Preexisting-condition protections has been the political lightning rod in the push by President Trump to overturn the ACA in the courts, but eliminating the Medicaid expansion would also pull the rug out for millions of people who have been covered in states that have expanded,” said Larry Levitt, a senior vice president at the nonpartisan Kaiser Family Foundation.

Democrats hope to parlay the ballot initiatives into a debate over health care coverage, repeating the strategy they used in 2018 to retake the House.

“Missouri became the 38th state to expand Medicaid last night. South Carolina should be the 39th,” Jaime Harrison, a Democrat trying to upset Sen. Lindsey Graham in South Carolina, tweeted Wednesday.

Kansas Gov. Laura Kelly, a Democrat, said Missouri’s decision makes her state an outlier among its neighbors.

“Every single Kansas voter must ask themselves why, year after year, Republican leadership in the Legislature has blocked expansion,” said Ms. Kelly, who pushed to expand the program but ran into Republican opposition.

Voters in Oklahoma and Missouri made their decisions to expand during a major health crisis. The fallout from the COVID-19 pandemic cuts two ways, however, with conservatives fretting about stressed budgets and pro-Obamacare voices saying Medicaid is needed now more than ever.

“On the one hand, Medicaid coverage is more important than ever as millions lose their jobs and employer-based health insurance at the same time as they fear getting sick from COVID-19,” Mr. Levitt said. “On the other hand, states are facing massive budget shortfalls as revenues drop, making it more difficult to pay for their share of expanded Medicaid.”

Missouri Gov. Mike Parson, a Republican, opposed the expansion initiative and said it will have a “significant impact” on next year’s budget.

“However, Amendment 2 is now a part of Missouri’s Constitution, and we will find a way to move forward,” he said.

The White House did not say whether Mr. Trump’s forthcoming health care plan will address Medicaid, though it argued that the president is already delivering change.

“President Trump continues to act in delivering better and cheaper health care, protecting Americans with pre-existing conditions, lowering prescription drug costs, and defending the right of Americans to keep their doctors and plans of their choice,” White House press secretary Kayleigh McEnany said. “President Trump recently issued four executive orders to lower the cost of prescription drugs, including making insulin and EpiPens available at low cost to low-income Americans. There will be more action to come in the coming weeks.”

Earlier in his term, Mr. Trump pushed to overhaul Mr. Obama’s program by converting federal Medicaid funding into a block grant or per-capita system.

The Republican idea couldn’t get off the ground after initial repeal-and-replace ideas failed in 2017.

Since then, Mr. Trump has tweaked Obamacare where he can, gutting the individual mandate and expanding the use of bare-bones plans that don’t comply with the 2010 program’s coverage rules, while allowing states to impose work requirements on some Medicaid recipients.

Sign up for Daily Newsletters