The Cold Civil War
Deep into the grimmest months of the COVID-19 pandemic, Medicaid officials devised a stopgap plan that proved to be one of the federal government's most consequential decisions. To slow the spread of the deadly and contagious disease and ease up on paperwork during the public-health emergency, the feds ordered states to maintain coverage for Medicaid recipients. As a result, Medicaid rolls grew by over 23 million beneficiaries during this period, swelling to around 95 million Americans .
But in March 2023, with the virus more or less contained, Medicaid eliminated this "continuous enrollment" provision. States could manage their Medicaid rolls any way they saw fit. And the results of this experiment were revealing.
Net Medicaid enrollment across the country has fallen by 14.1 million since last March, compromising the health of millions of very poor people. At one end of the spectrum, Montana, Utah, Idaho, Oklahoma, Texas, and South Dakota each shed at least half of their enrollees who were on Medicaid when continuous enrollment was in effect. At the other, North Carolina, Oregon, Maine, California, Connecticut, and Illinois each have disenrolled 20 percent or less. (North Carolina is an outlier, because it expanded Medicaid when this all started last year.)
Florida cut short postpartum care for poor mothers due to a "computer error"; Arkansas dropped 427,000 recipients in the first six months, often for procedural reasons like not returning a renewal form. South Dakota, Montana, and Idaho led ten states that "disenrolled so many children in 2023 that they had fewer children enrolled at the end of the year than prior to the pandemic," according to Georgetown University.
As one consumer advocate told NPR , "We have seen some amazing coverage expansion in places like Oregon and California. But if you live in Texas, Florida, and Georgia, since the pandemic your health coverage has been disrupted in ways that were preventable by state leaders."
By now you may have figured out the pattern. In the vast majority of cases, states controlled by Republicans moved quickly to cull the Medicaid rolls, and states controlled by Democrats kept them on much longer. And this holds across nearly every policy area.
Red states have the most oppressive abortion restrictions; blue states have more realistic reproductive policies. If you can carry a concealed weapon without a permit, you are likely in a Republican state; if you need to pass a background check to purchase a firearm, you are in a Democratic state. Republican states have the weakest LGBTQ+ protections; Democratic states have the strongest. The 13 states with paid parental leave are all Democratic. Of the 20 states with a $7.25 minimum wage, 15 are Republican trifecta states and three have Republican legislatures.
In 1967 in a speech at Stanford University , Martin Luther King described "two Americas": One with all the "material necessities for their bodies" and the other "perishing on a lonely island of poverty." Nearly 60 years later, King perfectly captures the two Americas that we're dealing with right now, bounded by a geographical reality: The laws that you live under are determined by the policymakers in the state where you live.
over the institution of slavery, leading to the epic clash between North and South 160 years ago. Partisans have eyed each other warily ever since. The post-Reconstruction era saw states splitting along the virulent racial, social, and economic prejudices that survived the Civil War. Yet as the federal government asserted itself during the New Deal, using incentives like highway funding to force standardization, interstate economic variation began to narrow. But a nearly all-white, largely Southern Republican Party took hold only after Ronald Reagan secured the White House, and state policy started diverging wildly once again.
Over the last 30 years, a state government's partisan orientation is the overwhelming predictor of the policies it will adopt. One University of Chicago study shows that the effects of party control on state policies have doubled since the early 1990s. Divergent ideas and beliefs have always been with us, but divergent outcomes at the state level are new, and growing.
One reason for this is that there are fewer institutional brakes on policy disagreements. In 1980, 26 states split control of the legislature and the governor's office, and each branch checked the other. But today, only ten states have split control; a whopping 40 states have unitary Republican or Democratic governance. With state lawmakers often responsible for gerrymandering state Senate and House districts beyond recognition, they cement one party's control well into the future by picking their own voters, even if their overall electorates are closely divided.
A federal government mired in gridlock and dysfunction also has set the stage for partisan disrupters to surge into states. Legislative meddling has become a cottage industry for corporate bill mills like the American Legislative Exchange Council (ALEC), which produces ready-made legislation for conservative lawmakers. While states have long produced models for national policies, encouraging the federal government to catch up to better ways of doing the people's business, today policy extremism in the states has become an end in itself.
Over the last 30 years, a state government's partisan orientation is the overwhelming predictor of the policies it will adopt.
Policy extremism has eroded quality of life in America. As much as half of the gap between the states in life expectancy is due to geographic variation. A 2023 study found that more liberal policies on tobacco, labor, immigration, civil rights, and the environment correspond to a one-year increase in how long a state's residents live. (In this special issue, Kalena Thomhave takes a closer look at Oklahoma and Connecticut, which had the same life expectancy in 1959 and a 4.7-year spread as of 2019.)
Of the ten states with the highest rates of uninsured residents, seven are controlled fully by Republicans. Of the ten with the fewest uninsured, seven are controlled fully by Democrats. The ten worst health systems in the country, according to the Commonwealth Fund, are all in red states. Eight of the ten states with the most COVID-19 deaths are Republican-led; so are ten of the 12 states with the highest rates of smoking-related cancer deaths. Firearm deaths are lower in blue states and higher in red states. Even obesity levels show this correlation: Ten of the 12 states with the highest percentage of obese residents have Republican trifectas.
Where you live, in short, can determine how long you live.
This wide gulf between healthy and ailing America is bad enough. But red states in particular want their policy preferences to be reflected across the nation, and have engaged in numerous aggressive tactics to make that a reality.
Texas and Idaho have enabled private citizens to sue anyone providing assistance to help their residents obtain an abortion, even if another state provides the care. Cities and counties throughout Texas have barred the use of their roads for abortion travel. Texas Gov. Greg Abbott has sent over 120,000 migrants by bus into other states and dumped them there. Red-state attorneys general have issued subpoenas to force health facilities in other states to release information about gender-affirming care sought by their own residents.
Anti-ESG laws require businesses and financial institutions to change corporate governance practices in order to operate in red states. Companies and conservative advocates seek out red-state courts with conservative judges to obtain nationwide injunctions on regulatory policies affecting all of us. Red-state lawmakers have even seized the tools that cities use to set their own laws (see Texas and Austin, or Tennessee and Nashville).
Democrats have notched victories in states they control as well, but by and large they have not adopted draconian measures to force other states to accept their ways of operating. Red states, by contrast, aren't interested in peaceful coexistence; they appear determined to carry on their battle for national political dominance. Just enough terror has been unleashed to signal that the state of the union is not strong. The melting pot threatens to boil over, a once savory recipe spoiled beyond recognition. You can call it a cold civil war.
understanding of this historical moment. Developments at the state level are too often ignored in the corridors of power in Washington, where Congress and the executive branch intend to set policy for the whole country. But the likelihood that this push and pull will grow stronger as the years go on forces us to pay attention, regardless of national electoral outcomes. If Donald Trump wins, he has already signaled the willingness to use federal leverage to force changes to blue-state policies, such as withholding funding for vital needs like firefighting. If Kamala Harris wins, conservatives will retreat to their power centers, use partisan courts to their advantage, and continue to develop pernicious strategies to make other states bend to their will.
This special issue of the lays out interstate divergence on anti-poverty programs, education, climate and energy, jurisprudence, labor rights, and more. We profile Texas, the intellectual and emotional center of this strategy of policy maximalism and interstate hostility. We look at the ways in which red states aren't settling for dominion within their own borders, and seek control over others. And we lay out how blue states can fight back against red-state incursions into their policy territory, build power across the country, and advance critical policy objectives that preserve hard-fought rights.
Some may fear that a strategy of calibrated counteraggression could launch the country into a series of damaging reciprocal exchanges, much like the various skirmishes between free and slave states that sparked civil war. But there's another path that doesn't signal endless internecine strife, with strategic actions that can also lower the temperature, by proving to conservatives that their adversaries in the blue states will not be run over.
