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A roundtable of area legislators and health care activists is held to discuss Eddie Rispone's plan to repeal medicaid expansion on Wednesday, Oct. 30, 2019, at Abacus in Lafayette, LA.

Gov. John Bel Edwards and his team has spent much of the last week at forums in Lafayette, Alexandria and elsewhere talking about the good Medicaid brings a state as poor as Louisiana and how the policies backed by his Republican opponent would lead to a lot of people losing their government-paid health insurance.

Looking from the front, reminding voters that as governor Eddie Rispone likely would spell significant changes in health care policies — including the end of coverage for many — for about 40% of the state’s elderly, children and working poor would seem a good strategy.

But the sting is in the tail: a majority of voters in the parishes that rely on Medicaid the most (and food stamps for that matter) don’t care.

For nearly a decade, mainstream Republicans, Fox News, right-wing radio and bloggers have relentlessly belittled President Barack Obama’s Affordable Care Act and the role Medicaid plays in it. Despite constant criticism, however, an LSU poll in April found 76% of the state’s residents supported changing eligibility rules to include those who made too much money to qualify for the safety-net insurance but too little to buy adequate coverage on the private market.

After years of resistance from Republican Gov. Bobby Jindal and the GOP dominated Legislature, Democratic Edwards ordered the state to expand Medicaid coverage to the working poor within hours of being sworn in as governor in 2016.

That same LSU poll also found that 55% of the state’s residents were unsure whether Louisiana had, in fact, expanded Medicaid.

In the Oct. 12 primary, many of the very people who benefited most from the Edwards’ expansion voted against him in a major way, according to an analysis by this newspaper.

Thirty-two parishes went hard against Edwards, with the incumbent receiving 40% or less of the ballots counted. About half the residents in each of those parishes receive Medicaid, about a quarter of whom joined under the Edwards expansion. In a dozen of those parishes, nearly two-thirds are enrolled. In 20 of the anti-Edwards parishes, the majority of Medicaid enrollees are white.

Edwards racked up votes in the urbanized areas along Interstate 10 — he received 170,572 ballots in Baton Rouge and New Orleans alone — where the economy is resurgent and good-paying jobs are plentiful.

But the governor was stiff-armed in the parts of the state that aren’t doing so well. The 32 small and rural parishes are in north or central Louisiana and much of Acadiana, where Edwards received 167,706 votes. Another 411,132 people voted against a second term.

“It’s a partisan issue, and I think those voters have been going in that direction for a while,” Edwards said, adding that lost on a lot of voters is just how important Medicaid is to the state’s economy in general and to rural parishes in particular.

Rural hospitals are paid through insurance claims for the care they provide. For patients on their own policies, that money comes from private insurers. For those on Medicaid, the federal government picks up most of the tab — 90% for those enrolled during expansion. Without that Medicaid money, those rural hospitals will have to provide care without reimbursement, Edwards said.

Rispone wants to “freeze” enrollments, though he won’t say for how long. About other Republican states that considered or enacted a plan similar to Rispone's,  John Kasich, then Ohio's Republican governor, said a freeze amounted to a rollback.

About 102 rural hospitals have closed nationwide — though none in Louisiana. But that could happen with a freeze, Edwards said.

In addition to providing health care, most rural hospitals are the largest employer in their communities. “Good luck trying to get a company to invest in a community that doesn’t have hospital,” Edwards said.

Rispone said he’s not a politician and doesn’t know why people in those 32 parishes would vote against their own economic interests, other than having been persuaded that freezing enrollment will maintain Medicaid for those most in need.

Pollster John Couvillon said part of the reason is that Louisiana has shifted over the years from voting economic interests to voting party. Most of the rural voters identify as conservative, for whom anti-Medicaid rhetoric resonates. “That’ll change if people start losing their health care coverage,” Couvillon said.

Political scientist G. Pearson Cross, of the University of Louisiana in Lafayette, thinks it’s more cultural. Many people look at Medicaid and other government programs as inherently corrupt and used only by people who are lazy.

“It’s about identity: ‘I don’t take government handouts, and I’m not like those people who do,’” Cross said. “It’s a kind of slap-yourself-in-the-head moment. It’s all said without a hint of self-awareness. … They simply find a way to justify it to themselves.”

Email Mark Ballard at mballard@theadvocate.com.