Election Results 2014: The Effect on Medicaid Expansion

NOV. 4, 2014 - New York Times

Josh Barro and Margot Sanger-Katz

The re-election of four Republican governors means that the future of Medicaid expansion under the Affordable Care Act is unlikely to change course.

Republicans in Florida, Wisconsin, Maine and Kansas won their bids for re-election. Three of them ・Scott Walker in Wisconsin, Sam Brownback in Kansas and Mr. LePage in Maine・oppose expansion of the program. Rick Scott, the Republican governor of Florida, has endorsed the expansion, which would extend coverage to an estimated 848,000 people, but has never advocated for it forcefully, and he is not expected to now.

And one state that has expanded its program might reverse course. In Arkansas, the legislature has to reauthorize the program every year with a three-quarters majority, leaving the expansion vulnerable to political shifts. Asa Hutchinson, a Republican who appears to be unenthusiastic about the expansion, was elected governor. And opponents of expansion picked up two critical votes in the state Senate.

Alaska remains the one state where the election could lead to further expansion of the program.

The health law sought to expand Medicaid to every resident earning below an income threshold of about $16,000. But a 2012 Supreme Court decision made the expansion optional. (To get a sense of what the Affordable Care Act might have meant without that ruling ・or just to get a sense of what expansion might mean to these states ・see our article on what the Medicaid expansion might have looked like.) So far, 27 states and the District of Columbia have decided to expand their programs. The remaining states, all but three led by Republican governors, have decided against expansion.

There are still states that might expand in the years to come. But the election results did not replace any expansion-opposing governors with expansion advocates.

Here are the states we’ve been watching:

Maine

The legislature there has voted for a Medicaid expansion five times, but each time it has been vetoed by Governor LePage.. An estimated 28,000 people would sign up for coverage by 2016 if the program were expanded, according to estimates from the Urban Institute.

Alaska

Gov. Sean Parnell, a Republican, opposes Medicaid expansion. He has noted that the coverage gap in Alaska is relatively small because many of the people who would become eligible for expanded Medicaid are native Alaskans served by Indian Health Services or veterans served by the Veterans Affairs Department. Mr. Parnell appointed a commission to recommend state-based reforms to close the remaining gap; conveniently, it is set to report back on Nov. 15, shortly after the election.

Bill Walker, an independent candidate running with support from most Democrats, supports the expansion. He notes that Medicaid is more comprehensive than coverage from the V.A. or from Indian Health Services, and that accepting Medicaid dollars would free up Indian Health Services to spend on other needs. Unlike in some states, Alaska’s debate over Medicaid expansion has focused on a lot of technical details and not on broad ideological ideas about government. As such, it’s likely that the governor’s position will drive the policy choice the legislature makes next year. The Urban Institute estimates that 26,000 Alaskans would gain coverage through expansion.

Wisconsin

Mr. Walker, who was re-elected, has opposed expansion. Mr. Walker notes that Wisconsin already had unusually generous Medicaid eligibility rules before the Affordable Care Act. You can see that in the numbers from the Urban Institute: Expanded Medicaid in Wisconsin would add coverage for 120,000 people; Florida, with about three times the population, would have seven times as many new Medicaid enrollees.

Florida

In 2012, Governor Scott said that he would oppose expansion; in 2013, he changed his position to support it. But he has not pressed the issue in the legislature, where opposition has been led by Will Weatherford, the Republican House speaker. Now that Mr. Scott is re-elected, the legislature is likely to continue to block Medicaid expansion, especially since the new state House speaker, already selected, has come out strongly against it. Coverage for 848,000 people is at stake, according to the Urban Institute estimate.

Kansas

Gov. Sam Brownback has strongly opposed Medicaid expansion, and he has the backing of hisRepublican-held legislature. It passed a law last year barring any governor from accepting expanded Medicaid dollars without explicit legislative approval. About 100,000 Kansans stand to gain coverage if Medicaid is expanded.

Arkansas

Gov. Mike Beebe, a Democrat, and the state’s Republican-led legislature developed one of the country’s most innovative compromises on Medicaid in 2013, known there as the “private option.” The state uses federal Medicaid dollars to buy private health plans for its low-income residents. Enrollment in the program has been significant ・more than 200,000 people have already signed up ・but to stay in place, the expansion must be authorized by the legislature every year by a three-fourths majority. This year, Mr. Beebe worked hard to keep expansion in place, and the program was reauthorized with no votes to spare in the state senate. His replacement, Asa Hutchinson, a Republican who has expressed only lukewarm support for the private option program, is likely to be a less forceful advocate. Democrats also lost ground in both the state house and senate, meaning it may be difficult for “private option” advocates to find the votes they need to keep it alive. About 205,000 people have already gotten coverage through the program, and would lose it if the expansion were not renewed.

Pennsylvania

Pennsylvania will definitely expand Medicaid next year, but election results may determine the shape of the program in future years. Gov. Tom Corbett, a Republican, and his legislature had adopted an expansion to start in January, under a federal waiver with some rules that Democrats in the state oppose. Mr. Corbett lost to his Democratic opponent, Tom Wolf; if Democrats pick up many legislative seats, it’s possible they will put their own stamp on the expansion format, though probably not right away.

Other States

There are states without governor’s races this year where Medicaid expansion could happen in 2015. Utah’s Gary Herbert is reportedly in final talks with the federal government about terms for expansion. It appears that Utah, like Arkansas, will use federal Medicaid money to buy private health plans; it may also require beneficiaries to participate in work training. Indiana’s Mike Pence has also been negotiating with federal officials, though he does not seem to be as close to a deal. In Virginia and Missouri, Democratic governors support expansion but have had little luck with their legislatures so far.