Missouri recently became the fifth straight red state to approve Medicaid expansion by referendum, joining Idaho, Nebraska, Utah and Oklahoma. Does that surprise you? Not me.

As a U.S. senator from Minnesota, I saw how passionate folks in the rural areas of our state are about Medicaid expansion. Why? Because Medicaid expansion has been an enormous boon to rural counties. And now, in this time of COVID-19, folks in rural America need it more than ever.

Over 200,000 Minnesotans are now covered through Medicaid expansion. Because so many of them live in rural areas, rural hospitals had previously found themselves on the line for lots of what is called “uncompensated care” — mainly for emergency room visits by low-income folks who had no insurance and no ability to pay for their enormously expensive emergency room care.

After the Affordable Care Act became law and Medicaid expansion was adopted in our state, these hospitals suddenly found themselves with a lot less uncompensated care and, therefore, a lot more resources. Now that rural hospitals didn’t have to eat the costs of uninsured patients, they had money they could spend for more doctors, nurses, technicians, technology, rehabilitation therapists, dietitians — even better food! Suddenly, these rural hospitals were able to significantly expand their scope of practice.

Not only did rural Minnesotans have access to more specialists and sophisticated medical equipment (including ventilators), now they could receive regular free checkups from their physicians, reducing the incidence and severity of the comorbidities that make people so vulnerable to the coronavirus.

During his 2016 campaign, President Donald Trump promised to replace the Affordable Care Act with “something terrific.” When Trump was sworn in, Republicans in Congress had been promising to repeal and replace the ACA since it had been signed by President Barack Obama. (Hence, you see, Obamacare.) I must say I had been curious about what they’d come up with in seven years, which turned out to be, approximately, nothing.

It appears that their extraordinarily well-funded think tanks had done extraordinarily little thinking in the interim, and Mitch McConnell ended up locking 13 white male senators in a committee room for a few weeks. What genius ideas did these guys, 11 from deeply red states, come up with? Get rid of expanded Medicaid.

As chairman of the Senate Rural Health Caucus, I was not at all surprised by the reaction of my constituents in small cities and agriculture-centered communities when Republicans in the House and Senate put forward their legislation to repeal and replace the ACA.

Soon after the Republicans dropped their bill, I took a little tour of rural hospitals in red areas of the state. By 2017, many of these hospitals had become the largest employer in the county. Not only were lower income Minnesotans now getting regular care from their doctors, but practically everyone in the area had found themselves the beneficiary of the improved scope of care now in their own community’s hospital.

In one town meeting, a gentleman told me that the hospital food had improved so much that he and his wife would go to the cafeteria for the lasagna and the salad bar on date night before heading off to the movies. She likes Tarantino.

But more than anything, the folks I met at those public meetings were plain freaked out. A woman in tears told me that she and her husband both worked full-time. If they cut Medicaid, who would go to her mother’s house in place of her home health aide to provide the care she needed? And where would they put her? Not in a nursing home. As I learned later that day in Moorhead at a roundtable surrounded by frightened seniors, the owner of their nursing home was afraid he might have to close down.

It wasn’t until Republicans in Congress made their health care proposal that a great majority of Americans realized they’d rather build on the strengths of the ACA than lose its benefits. That’s why health care was by far the biggest issue for Americans in 2018. The biggest issue in this year’s campaign is Trump’s handling of the coronavirus crisis.

Who knew that the president who exclaimed, “Who knew that health care was so complicated!?” would be so bad at handling a global pandemic?


Al Franken is a former Democratic U.S. senator from Minnesota.