A new wave of Medicaid expansion is unlikely to take hold across the country anytime soon. Many state Legislatures are already starting to wrap business for the year. | Getty
The epic collapse of the Obamacare repeal bill created an odd opportunity for 19 states that have long shunned Medicaid expansion.
Billions in Obamacare cash remain on the table. And for the first time, that cash comes with a Trump administration promise to give states unprecedented flexibility to remake the program with a conservative slant — for instance, by imposing work requirements or requiring more recipients to pay premiums.
Story Continued Below
Yet with few exceptions, most of the holdout states are walking away from the money and what they regard as a broken entitlement program. Some even want to shrink the program they have.
“The cost of expanding Medicaid under Obamacare is irresponsible and unsustainable,” said Kansas Gov. Sam Brownback on Thursday after he vetoed an expansion bill.
That stance underscores the uncompromising ideological component of the health care debate — and a key reason the House GOP repeal bill failed. Conservatives wanted the expansion covering more than 11 million low-income adults halted fast, while moderates didn’t want it stopped at all.
For years, these 19 holdout states have walked away from piles of federal cash to expand the program — even after two Supreme Court rulings and the reelection of Barack Obama in 2012 further entrenched the Affordable Care Act. These mostly Republican-led states argued that expanding the program would bust their budgets and make it harder to dismantle the health care law once Republicans gained full control in Washington.
But for some lawmakers and governors, the objections go much deeper than that.
Deep-red Kansas is a case in point. Just days after the repeal effort collapsed in Washington, the Kansas Senate advanced an expansion bill that would cover an estimated 180,000 people. Lawmakers would need to pick up a few votes to override Brownback’s veto — an uphill battle.
In several other states, like South Dakota and Utah, Republican governors’ expansion plans — which began under the Obama administration — have been scuttled by their legislatures. Those governors concede that even under Trump, there’s little they can do now to convert reluctant state lawmakers.
“I don’t know that it changes my position or belief about what could be done,” said Utah Gov. Gary Herbert, who met with Trump and administration officials this week, just days after Republicans yanked their health bill from the House floor. “There’s still some uncertainty out there about what tomorrow’s going to bring.”
The result is a status quo for the Obamacare expansion even though the feds have paid the full cost for the first three years, and will pick up at least 90 percent for the foreseeable future — far more than what it pays for the traditional program.
Medicaid expansion supporters see a new opportunity for states to join the program after the deeply unpopular repeal bill was shelved. Yet states that seem the likeliest to expand Medicaid this year had been already working to adopt the program.
North Carolina Gov. Roy Cooper, a Democrat, tried to expand the program unilaterally upon taking office earlier this year, but Republican lawmakers are challenging him in court. In Maine, voters will consider a ballot initiative in November after conservative Gov. Paul LePage has vetoed several expansion bills.
“This is still an opportunity for Maine,” said Robyn Merrill of Maine Equal Justice Partners, which helped get the initiative on the ballot. “We have every reason to move forward at this point.”
Meanwhile, Virginia’s Democratic governor, Terry McAuliffe, renewed a push to expand Medicaid this week, a request that Republican lawmakers have rejected for the past four years. South Dakota Gov. Dennis Daugaard, a Republican, also said this week that he won’t bother trying to push through the Medicaid expansion plan he proposed in 2015.
Still, conservative groups who’ve fought Obamacare implementation say they remain worried the ceasefire in Washington could embolden some states to give expansion a second look.
“When there’s funding on the table there’s going to be interest in pursuing that,” said Mia Heck of the American Legislative Exchange Council. “I don’t think it’s going away anytime soon.”
Some speculate that Georgia Gov. Nathan Deal may take steps to claim the money. Deal said this week he would try to negotiate Medicaid changes with the Trump administration, though he refused to say whether he would pursue expansion, which would cover an estimated 600,000 low-income Georgians.
Before the election, Georgia hospitals and the state’s Chamber of Commerce had circulated plans for a conservative expansion model they hoped state lawmakers could support. Groups pushing for expansion are optimistic Deal might consider moving forward after the repeal bill fell through.
In Tennessee, two years after Republican Gov. Bill Haslam failed to rally support for Medicaid expansion, a handful of key state lawmakers are considering a plan to phase in coverage to more low-income adults. State Rep. Cameron Sexton, who chairs the House’s health care committee, said Monday they will restart discussions about their plan now that Obamacare isn’t under threat of immediate repeal.
The first phase would only expand coverage to adults with serious mental health and substance abuse issues.
“Would Tennessee do a full expansion? Probably not,” Sexton said. “I’m not sure Tennessee’s quite there yet.”
Many state legislatures are already starting to wrap business for the year, decreasing the likelihood other holdouts will soon look to expand. Texas and Florida — the two states that would see the largest coverage gains from the program — remain firmly opposed.
“We have been pretty strong in our ‘not expanding Medicaid stance’ in the state,” said Texas state Sen. Dawn Buckingham. She said the state is looking for more flexibility from Washington “so we can hopefully innovate and have patient-centered health care for the first time in a very long time.”
Renuka Rayasam contributed to this report.