So, Virginia has expanded Medicaid.

Depending on your perspective, this is a great day because 400,000 people — many of those often called “the working poor” — now will have health insurance.

Or it’s a black day because it will mean the fiscal ruination of the commonwealth.

The former is certainly true. Time, as always, will tell whether the latter comes to pass. It’s not too soon, though, to assess the politics of this landmark action by the General Assembly. We are hardly the first to point out that the passage of Medicaid expansion shows that “elections matter.” They really do. However, the action the General Assembly took this week can be traced back through a whole series of elections, one of them as far back as 1991. Let’s get started.

The 2016 presidential election and the 2017 House of Delegates elections. These are the two obvious ones. The election of Donald Trump in 2016 thrilled (most) Republicans at the time, but also had the unintended consequence of energizing Democrats in a way they haven’t been in a long time. One of the first opportunities came in Virginia’s state elections. Democrats had talked optimistically about picking up six or eight seats in the Republican-controlled House of Delegates. Instead, they won 15 — and came within a tiebreaker drawing of winning a 16th. That left Republicans clinging to the narrowest of margins in both the House and state Senate, which wasn’t on the ballot.

It’s safe to say that the results of those elections in November 2017 led directly to Medicaid being expanded in May 2018. That’s not the entire story, though. For one thing, the House wound up passing Medicaid expansion by a lopsided vote of 67-31 — with 20 (!) Republicans voting for it. Were the votes for Medicaid expansion really there all along? Maybe yes, maybe no. The 2017 elections certainly scrambled the dynamics in the House in a way that made the conversation — and ultimately the conversion — possible.

Let’s not forget, though, that the real break came on the Republican side, when Del. Terry Kilgore, R-Scott County, announced that he would support Medicaid expansion, provided it came with a work requirement. That wasn’t what Democrats had in mind at all, so you can make the case that Republicans didn’t back a Democratic plan but Democrats backed a Republican plan. House Speaker Kirk Cox hailed this as “the most conservative set of reforms to Medicaid in the nation,” although that was not a view shared by most of his caucus. Still, who would have thought a year ago that a Republican Speaker of the House would have voted for Medicaid expansion in any form?

The 2017 gubernatorial election. Just as it’s impossible to imagine Medicaid expansion happening without the new line-up in the House of Delegates, it’s also impossible to imagine it without Ralph Northam in the governor’s chair. The Democratic governor just accomplished in four months what his predecessor, Terry McAuliffe, couldn’t do in four years: He got a Republican-controlled legislature to expand Medicaid.

If Republican Ed Gillespie had won the governorship, this would not be happening. If the lieutenant governor’s race had gone a different way, this still might not be happening: Democratic Lt. Gov. Justin Fairfax broke a key tie vote at one point in the Senate, and his presence behind the gavel complicated Republican parliamentary moves.

Now here’s a thought experiment: Could Tom Perriello — the liberal heartthrob whom Northam defeated in last year’s Democratic primary — have accomplished the same thing? We’ll never know, but we’re guessing not, for two reasons. His liberalism might have repelled Republicans on sight. Plus, he had never served in the legislature. Northam’s deft handling of Medicaid expansion shows the value of having a former legislator as governor (plus the virtue of a certain amount of pragmatism). Northam could talk to Republican legislators in a way that McAuliffe never did, and Perriello might not have. One of the Senate Republicans who voted for Medicaid expansion was Ben Chafin, R-Russell County. His switch came as a surprise to many. The Richmond Times-Dispatch suggested that Chafin “may have gotten a friendly nudge from Northam when he signed a tax break for Virginia coal opposed by Democratic greens.” McAuliffe always vetoed coal tax credits; Northam may have had a more nuanced view. He likely saw that a coal tax credit may have been a small price to pay for Medicaid expansion.

The 1991 House of Delegates elections and the 1995 state Senate elections. These are obscure but highly relevant, which shows just how long the thread of history runs. In 1991, Democrats controlled the House and gerrymandered Del. Emmett Hanger, R-Augusta County, out of his seat by putting him in a district they knew he’d lose. And he did. Four years later, though, he came back. He ran for the state Senate, and ousted longtime Democratic incumbent Frank Nolen. That set Hanger on a path to having the seniority to become co-chairman of the Senate Finance Committee two decades later. Hanger had always been the Republican most likely to support Medicaid expansion but his role as committee co-chairman was vital to its passage. When fellow co-chairman Tommy Norment, R-James City County, tried to pull a parliamentary trick that would have doomed the measure, Hanger simply gaveled the meeting adjourned. That might not have happened if Democrats hadn’t sliced and diced him out of the House back in 1991.

So now what? One of the most fascinating dynamics in this whole debate has been the split between rural Republicans. Some of the most strenuous opposition to Medicaid expansion came from rural Republicans, such as Stanley, who feared the fiscal implications. And in the end, the key Republican support for it also came from rural Republicans, such as Kilgore and Hanger and even Chafin, who were moved by economic considerations. In a floor speech, Chafin said he couldn’t deny that Medicaid expansion would help his constituents — and would also provide financial stability for the eight private hospitals in his district at a time when many rural hospitals are closing. “I came to the conclusion ... that ‘no’ just wasn’t the answer any longer,” he said. Some of the Republicans who voted for Medicaid expansion might face primary challenges as a result — so we might have more elections that matter. If they come, rural Republicans will be in for a fascinating conversation about the best way to build a new economy in rural Virginia.

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