New momentum for Medicaid expansion, as more Republicans conclude Obamacare won't get repealed

By James Hohmann
March 28 at 10:59 AM - The Washington Post

THE BIG IDEA: Paul Ryan promised his donors yesterday that he will keep pushing to overhaul the health care system this year, despite his failure last week. But in the 19 states that never expanded Medicaid under the Affordable Care Act, the calculus has quickly changed.

A lot of state legislators, including Republicans, are putting more stock in what the Speaker said Friday, that Obamacare will be the law of the land for the foreseeable future.

The bill that was being considered in the House would have phased out the expansion under the 2010 law, which has already grown the Medicaid rolls by more than 11 million people. It could have left states holding the bag over the next couple of years.

With Obamacare repeal less likely, opponents of expansion in the states have just lost their best argument.

-- The Kansas Senate voted last night to expand Medicaid, which would mean coverage for 150,000 currently uninsured Kansans. Senators cleared a procedural hurdle by a vote of 25-13. There will be a final vote today. Republican Gov. Sam Brownback has signaled a likely veto, but he’s also expected to soon get appointed to an overseas posting by President Trump. So the legislature might be able to try again soon.

“The failure of the federal effort to repeal the Affordable Care Act hung over the debate,” the Wichita Eagle reports of the floor fight. “Elections last fall swept a number of moderate Republicans and Democrats into (state) office, giving supporters of expansion a boost. … The House already passed the bill 81-44. The House vote and the initial Senate vote are just shy of the number needed to override a veto. Override takes 84 votes in the House and 27 votes in the Senate.”

-- In Georgia, Republican Gov. Nathan Deal announced yesterday that his administration is exploring changes to the state’s Medicaid program now that the House bill has gone down. A former congressman, he said he’ll get with HHS Secretary Tom Price, who hails from Georgia, about what kind of waivers the state might be able to get now to sweeten the deal. “We will be looking at those possibilities,” Deal said at a press conference. “We have not formulated any proposal at this time, but the waivers will be primarily restricted to our Medicaid program.”

“Georgia lawmakers in 2014 passed legislation that gives the Legislature the final say over any expansion to the Medicaid program,” the Atlanta Journal Constitution explains. “Georgia flirted with a wide-ranging waiver in 2015 under Barack Obama’s administration that would have sought more Medicaid money to help the state’s struggling rural hospitals and its big ‘safety net’ hospitals like Grady Memorial in Atlanta. But the state later quietly abandoned those discussions.”

-- In Virginia, meanwhile, the failure of Congress has emboldened Democratic Gov. Terry McAuliffe to renew his stalled crusade to expand Medicaid. Yesterday he proposed an amendment to state budget language to give him power to set an expansion in motion, and called on the Republican-controlled General Assembly to immediately begin making plans. Republican legislators were unmoved by the plea, saying they would reject the amendment and that they stood firm against expanding Medicaid. But it ensures that Medicaid expansion will now be a top issue in this year’s open gubernatorial contest. (Gregory S. Schneider has more.)

-- Forbes Magazine says to keep an eye on other places like North Carolina, which now has a Democratic governor. “And there may be even more states that will resurrect state legislative efforts to expand Medicaid. Before Trump was elected … Idaho, Nebraska and South Dakota were considering expansion,” notes Bruce Japsen. Legislators stopped debating expansion in those places when it seemed like the ACA would be repealed.

“In Maine, GOP Gov. Paul LePage has vetoed several bills to expand Medicaid passed by the state’s Democratic-controlled legislature, most recently last year. But Mainers will get a chance to vote on expansion in a referendum this November,” the Huffington Post notes.

-- A robust debate over Medicaid is playing out this week in Arkansas, as well. “An effort to continue the hybrid Arkansas Medicaid expansion another year failed (last night) in the state Senate,” the AP reports from Little Rock. “The budget bill for the state's Medicaid program and the expansion failed on two votes. … Legislative leaders said they planned to try again with the proposal on Tuesday, and were confident they had the votes needed. The top Republican in the Senate said he didn't believe the program would be blocked while the future of the federal health law remains in limbo. ‘I don't think there's sufficient will right now to start blocking budgets when we don't even know what's going to happen or how long it's going to take,’ Senate Majority Jim Hendren said after the votes.” More than 300,000 people are on Arkansas' hybrid program, which uses Medicaid funds to purchase private insurance for low-income residents.

-- Once Medicaid is expanded, it is politically very hard to take coverage away from people. Key opponents of the House GOP bill, for example, included Michigan Gov. Rick Snyder and Ohio Gov. John Kasich, two Republicans who chose to expand Medicaid. A lot of the House moderates from the Tuesday Group who helped torpedo the bill hailed from expansion states and did so because they were concerned about Medicaid recipients in their districts getting hurt.

-- The New York Times has a good story on its front page today about how the health care fight last week showed the degree to which Medicaid has come of age: “When it was created more than a half century ago, Medicaid almost escaped notice. Front-page stories hailed the bigger, more controversial part of the law that President Lyndon B. Johnson signed that July day in 1965 — health insurance for elderly people, or Medicare, which the American Medical Association had bitterly denounced as socialized medicine. … But over the past five decades, Medicaid has surpassed Medicare in the number of Americans it covers. It has grown gradually into a behemoth that provides for the medical needs of one in five Americans — 74 million people — starting for many in the womb, and for others, ending only when they go to their graves.”

Some remarkable figures: “In 2015, the nation spent more than $532 billion on Medicaid, of which about 63 percent was federal money and the rest from the states. … Medicaid now provides medical care to four out of 10 American children. It covers the costs of nearly half of all births in the United States. It pays for the care for two-thirds of people in nursing homes. And it provides for 10 million children and adults with physical or mental disabilities. For states, it accounts for 60 percent of federal funding — meaning that cuts hurt not only poor and middle-class families caring for their children with autism or dying parents, but also bond ratings.”

-- Speaking to his donors on a conference call, Ryan insisted that the House got pretty close to passing his bill. “Basically … 90 percent of our members of the conference were there and ready to go and be a governing party and were happy with where we were, and around 10 percent were still in what I would call ‘opposition party mode,’” Ryan said on the call, an audio recording of which was obtained by The Post. “About 10 percent of our people, a particular bloc, just weren’t there yet, even with the president’s involvement.”

Ryan said he intends to work “on two tracks” as he pursues other elements of Trump’s agenda at the same time he keeps working on health care. “We are going to keep getting at this thing,” Ryan said on the call. “We’re not going to just all of a sudden abandon health care and move on to the rest. We are going to move on with rest of our agenda, keep that on track, while we work the health-care problem.”

Ryan did not disclose details of what the next iteration of the bill might look like, but he suggested that a plan was being developed in time to brief the donors at a retreat scheduled for Thursday and Friday in Florida, according to Mike DeBonis.

-- Former Rep. Tom Davis (R-Va.), who twice chaired the NRCC, warns in an op-ed for The Post today that Republicans could lose the House if they don’t quickly get their act together: “Unless the current trajectory is reversed, the Trump administration faces a difficult midterm that could undo its agenda and put House gavels and subpoena power in Democratic hands. … The collapse of the Republican health-care bill was a massive case of legislative malpractice. But playing the blame game and pointing fingers does little to advance the ball. … There is time to recover from a difficult start. This will entail compromise and, in some cases, working with Democrats to get half a loaf. But your fumbling of health care puts you in a weakened bargaining position and your internecine fighting dispirits the party base. As James Bond’s nemesis liked to say, ‘Choose your next move carefully, Mr. Bond, it may be your last.’”

-- But Republican strategists and elected officials are deeply divided over the best path forward. The Times's Jonathan Martin talked to players on both sides of the debate—

The case for moving on: “We’ve got a lot of time to do real things on infrastructure, to do real things on tax reform, on red tape reform, and really get the American economy moving,” said Rep. Steve Stivers (R-Ohio), the current chairman of the NRCC. “We do those things and we still have a lot of time to recover. … If you’re going to fumble the ball, better to do so in the first quarter of a football game. … I think we need to start negotiating with Democrats instead of the Freedom Caucus. They don’t know how to get to yes.”

Even if leadership tried and Trump re-engaged, it’s not clear they could get it done: “Not unless Harry Houdini wins a special election to help us,” said Rep. Billy Long (R-Mo.).

The case for circling back: “What troubles many Republican strategists is the specter of the party’s most reliable voters being bombarded by reminders of their leaders’ failure to address the health law. They fear a recurring story line sure to pop up every time insurance premiums increase, providers leave local networks, or, most worrisome, Republicans fund Barack Obama’s signature achievement. Conservatives … now warn that it is untenable to stand pat on the issue — and that lawmakers will face retribution if they do not return to the repeal-and-replace effort. ‘If people are looking at a situation where there’s no action on this, there are going to be conversations about primaries,’ warned Michael A. Needham, the chief executive of Heritage Action for America … which worked to scuttle the … bill last week.”

-- John Cornyn, the number two Republican in Senate leadership, said flatly that health care will not be attempted again via the budget reconciliation process. "It's clear it needs to be done on a bipartisan basis,” the Texan told the AP. 

-- Trump, for his part, tweeted last night that he’ll come back to the issue “as soon as ObamaCare folds”:

-- Greetings from spring training in West Palm Beach, Fla. The Nationals were in great form against the Mets yesterday. Bryce Harper and Trea Turner each homered twice, and Washington beat New York 6-0. The game showed why all the handicappers think the Nats will win the NL East again. The most memorable moments in Port St. Lucie were when Max Scherzer kept striking out Tim Tebow, the Heisman-winning quarterback who fizzled in the NFL and now wants to be a pro baseball player. Tebow was no match for our Cy Young winner, one of the best pitchers in baseball, who clearly relished the match-up. Then my dad and I drove down A1A and enjoyed some delicious Cuban food.