A photo of advocates in Helena, Montana, at a rally in support of a bill to protect the state's Medicaid expansion.
Advocates in Helena, Montana, rally in support of a bill to protect the state's Medicaid expansion. Matt Volz/AP

Whether Democrats gain the House or the Senate or neither, the 116th Congress will decide the fate of public spending on America’s most vulnerable families.

In run-up to Tuesday’s midterm election, U.S. voters have been hearing a lot about immigration, voting rights, and broken checks and balances. But health care is every bit as important to voters. While the Trump administration is closing its argument by drumming up nativist fears over the border, voters at the polls will be deciding the future of the social safety net.

If voters were not exactly aware how much social spending hinges on this election, that’s because conservative candidates have worked very hard to distract voters from their views (and votes) on the newly popular Affordable Care Act. With the politics of health care suddenly topsy-turvy, it’s worth looking at the benefits of social spending writ large.

Social safety net programs have a massive impact on the hardships experienced by low-income households, according to new research from the Urban Institute. Participation in three such programs—Temporary Assistance for Needy Families, the Supplemental Nutrition Assistance Program, and public health care—reduced the number of hardships faced by vulnerable families with children by 48 percent between 1992 and 2011. The future of these programs swings on the midterm election.

Red-state ballot measures may be the clearest indication of how far the health-care debate has moved since the 2016 election. Voters in Idaho, Nebraska, and Utah will choose on November 6 whether to expand Medicaid under the Affordable Care Act. Tight governors’ races in states such as Maine, where the outgoing GOP governor has blocked the state from implementing its expansion of Medicaid, could smooth the way toward an even greater embrace of public health care. In Montana, a ballot measure would let the people decide whether to preserve the recently enacted expansion.

Food assistance is also in play in this election. The next Congress will turn to passing the stalled farm bill early next year. Democrats oppose work requirements that the White House and Republicans in Congress want to impose for recipients of food aid under the Supplemental Nutrition Assistance Program.

Whether Democrats gain the House or the Senate or neither, the 116th Congress will decide the fate of the social safety net. The GOP is intent on shredding it: Republican Senate Majority Leader Mitch McConnell told Bloomberg that spending cuts to Medicare, Social Security, and Medicaid will be necessary to rein in a $779 billion federal budget deficit, which has jumped 77 percent since 2015 as a result of the GOP’s tax cuts.

McConnell also told Bloomberg that it will actually be easier for Congress to pass cuts to these so-called entitlement programs under divided government (i.e., if Democrats win the House). Perhaps that’s because a divided Congress would allow Republicans to share the blame with Democrats for the deeply unpopular decisions that only GOP lawmakers support. In several of the reddest states, voters appear ready to expand health-care coverage by 400,000 people. “It’s no coincidence that all four states are deeply conservative, because it’s conservative Republican elected officials who have resisted the expansion most strenuously,” writes HuffPo’s Jeffrey Young.

If programs such as expanded Medicaid coverage are now popular, that may be because voters have seen evidence that they work.

The Urban Institute’s Signe-Mary McKernan and Caroline Ratcliffe and Penn State University’s John Iceland find that the U.S. government’s effort to improve family well-being lags behind that of other developed countries, particularly given how wealthy this country is. The researchers measured the benefit of the social safety net by measuring setbacks in federal surveys, from hunger to evictions to delayed medical care.

Participation in TANF, SNAP, and Medicaid or the State Children’s Health Insurance Program—often some overlapping combination of these programs—helped low-income families avoid debilitating setbacks that can lead to homelessness or worse. Social safety net programs led to a 40 percent cut in instances of unmet medical or dental need, for example.

The flip side of this research: Social safety net programs are highly effective at helping families avoid hardships. Yet the highly partisan debates over reforming or curbing these programs—from Medicare and Medicaid to SNAP and TANF to Section 8—tend to focus on work requirements. Between 1992 and 2011, the percentage of families that reported experiencing hardships in America ranged from 43 percent to 51 percent—far too high for a country as prosperous as the U.S. is. Those figures would be higher still under the kind of cuts to SNAP, Medicaid, and Social Security that McConnell anticipates passing to offset growing deficits.

Voters are eager to have that conversation about expanding access to Medicaid—even in Idaho, where the health-care push has a legit chance of passing. The farm bill may be the first thing on the agenda for the next Congress, meaning the overall state of SNAP will be decided even as states navigate work requirements for food aid and health care. The safety net isn’t grabbing screaming headlines like a certain march of migrants toward the southern border, but the stakes couldn’t be higher.

Voters face a choice: Will we bolster the social safety net? Will we have any safety net at all? In a midterm election whose focus has fallen elsewhere, voters will choose to either protect these programs from marginalization, or boost the odds that they’ll be slated for elimination. On almost no other issue will Americans feel the consequences of this election so directly.

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