On Nov. 10, one week after the election, the Supreme Court will hear the Trump administration’s and Republican states’ case against the Affordable Care Act, in which they will argue that the entire law should be struck down. By Nov. 10, the U.S. will have blown past 200,000 coronavirus deaths. Millions will remain unemployed and uninsured. A refuge exists for those in the states that expanded Medicaid under the ACA. But Trump is arguing for Medicaid expansion to be struck down, as well.

In the period from March 1 to June 1, the most recent numbers available, about 1.7 million people enrolled in Medicaid for the first time, including children. That’s putting a big strain on some states, which have to come up with a match for federal Medicaid dollars and which have seen revenues shrink, in many cases dramatically, because of the pandemic. One of those states is Nevada, where The Washington Post recently reported from, featuring a number of people who never thought they’d be where they’re at now—needing Medicaid.

One is Jonathan Chapin, the former owner of a production company in Reno that handled concerts and weddings and parties at the Tahoe Biltmore Lodge & Casino. When the pandemic hit, he said “everything I knew all disappeared.” That included his wife’s job, and the family’s health insurance that covered the couple and their 11-year-old daughter. At the same time, he had an infected tooth. A quick application and approval for Medicaid got him treatment for that, and for a blood clot he developed in his left calf in April. And for his daughter’s braces. If not for Medicaid, “we would have sold things, or we would have gone into debt,” Chapin said. “I think about it all the time.”

This is phenomenal for him. It means that they, for now, are scraping by and able to make house payments, even though it means dipping into savings. “It’s part of being American. I started this business, and I was living the dream.” Now, “I have to ask” the state for help in getting insurance. The problem is that the state has had a 13.5% increase in Medicaid enrollments since the beginning of the pandemic. The state’s Medicaid director, Suzanne Bierman, says that “We believe Nevada has not yet seen the full impact as a result of the covid pandemic.” Unemployment in the state was 30.1% in April, and by now just one-third of the workers at the state’s casinos—the hardest hit, primary industry in the state—are back at work, and not all of them full-time. Unemployment in the state in July was 14%.

The state has a $1.2 billion deficit, and is required to balance its budget. The legislature is trying to cut $53 million from Medicaid costs through next summer, a 6% rate cut. They’re trying to do it by curbing payments to providers, which could mean fewer hospitals, doctors, and other providers willing to accept Medicaid patients. It also means great strain on providers, and the potential closure of facilities. Those are very big cuts. “Nevada is the extreme of what’s happening around the country,” Aviva Aron-Dine, vice president for health policy at the Center on Budget and Policy Priorities, told the Post. “The fear is that it’s the leading edge.”

These are economic threats on par with and even greater than the Great Recession—a 14% unemployment rate is higher than what the national rate was at the depths of that recession. In the Great Recession, Gov. Steve Sisolak noted in a report released in July, the state lost 180,000 jobs in the three years during and after. From April to June this year, he said, it had lost more than 250,000. Many of those jobs can come back if and when the pandemic is over. People will again want to flock to Nevada for the entertainment and the gambling and all the other things people go to Nevada for. But the state and its people have to hold out hope for that, and right now, there’s not a whole lot of hope.

That’s one of the reasons the Democrats are sticking by their demand for massive state and local aid in a coronavirus package. Nevada is the bleeding edge of the very scary economic disaster that could come. That disaster could be made much, much worse if Medicaid wasn’t there to buffer against it.

Medicaid rolls multiply while state revenues fall and Trump fights to kill the program 1