Tuesday’s re-election of Republican governors in closely contested races in Florida, Georgia, Wisconsin, Maine, and Kansas dims the chances of Medicaid expansion in those states, potentially preventing millions of low-income Americans from gaining access to affordable health insurance. But those aren’t the only states where the federally-funded expansion is in jeopardy after the GOP midterm sweep: the new Republican governors in Arizona, Arkansas, Illinois, Maryland and Massachusetts will have the power to threaten health coverage for hundreds of thousands who have alrready enrolled in expanded Medicaid.
Since the Supreme Court made Medicaid expansion an optional part of the Affordable Care Act, 27 states and Washington, D.C., have extended the program to individuals with incomes under $16,100. While most of those states expanded eligibility at the beginning of 2014, Michigan and New Hampshire came on later this year, and Pennsylvania’s expansion will start in January. Nationally, Medicaid enrollment has increased by more than 8 million people since last October and is seen as the biggest factor in reducing the number of uninsured Americans by about 25% this year, to the lowest level in recent history.
Heading into Election Day, advocates of the Medicaid expansion were hopeful that Democrats would win gubernatorial races in several key states where Republican governors have blocked the policy, leaving millions uninsured. Instead, Alaska remains the sole state where a new move to expand Medicaid could still happen, depending on who is ultimately declared the victor in the race between Gov. Sean Parnell (R) and challenger Bill Walker (I), who currently holds a slight lead. Walker has voiced support for expansion, while Parnell opposes it. Should Walker prevail after absentee ballots are counted, he still must get the support of his Republican-controlled legislature. About 26,000 Alaskans would gain coverage through expansion.
But GOP governors who were re-elected in Georgia, Kansas, Maine and Wisconsin all oppose Medicaid expansion, meaning their states’ programs are unlikely to be expanded. Florida Gov. Rick Scott (R) — also re-elected on Tuesday — has expressed support for expansion, but he has never pushed forcefully for it, suggesting he will not extend the program to the 850,000 uninsured Floridians who would qualify for Medicaid under the expansion. The rejection of the Medicaid expansion in those five states — Florida, Georgia, Kansas, Maine, and Wisconsin — has left almost 2.3 million people uninsured, and with the re-election of Republican governors in all five of those states, the situation is unlikely to change.
In other states, however, the future of the Medicaid expansion is less clear. Five states where officials have already established expanded Medicaid coverage now have new governors, some of whom have expressed intentions to unravel the state’s program. Here’s a rundown of those states:
In Arkansas, the future of the state’s “private option” Medicaid expansion could be in serious trouble with the election of Republican Asa Hutchinson as governor and GOP gains in the state House and Senate. Hutchinson replaces Democratic Gov. Mike Beebe, who devised the so-called private option with the GOP-controlled state legislature. More than 200,000 people enrolled in Arkansas, and states with Republican governors like Ohio and Pennsylvania adopted similar policies. But the private option was nearly defunded this year because Arkansas law requires spending bills to receive a 75 percent vote in both houses of the legislature. After Hutchinson’s gubernatorial victory on Tuesday and gains by Republicans in the state legislature, winning that 75 percent will be even harder next year. Hutchinson has said he wouldn’t have signed the bill creating the private option had he been governor at the time, but he has stopped short of calling for its repeal, instead saying he will assess its costs and benefits to “determine whether the program should be terminated or continued.” If Hutchinson and the new GOP legislature unravels Arkansas’ expansion program, at least 60,000 state residents would lose their newly-gained coverage.
In Arizona, Republican Governor-elect Doug Ducey is replacing Republican Gov. Jan Brewer, who infuriated GOP lawmakers when she strong-armed the Medicaid expansion through the Arizona legislature last year. More than 230,000 Arizonans enrolled under the new rules as of last month, the state reported. Ducey hasn’t voiced plans for undoing the expansion, but he wants the state to seek federal approval to alter the program, including adding a requirement that beneficiaries deposit money in health savings accounts. Ducey has also vowed to constrain Arizona’s spending on Medicaid as federal funding for the expansion drops from 100 percent through 2016 to 90 percent by 2022, pledging to “… protect our state from Obamacare, one of the worst laws ever signed by any American president.”
Republican Governor-elect Charlie Baker of Massachusetts, a former health insurance executive, did not include the state’s Medicaid expansion on his campaign platform, though he has pledged to cut the state’s health care program loose from Obamacare. “Massachusetts should be able to return to its own system that worked and as such governor Charlie will aggressively pursue a waiver for Massachusetts from the ACA,” a statement on his website reads. But given that generous Medicaid coverage was available in the state before the Affordable Care Act, scrapping the expansion would seem incompatible with protecting the program signed by then-Gov. Mitt Romney (R) in 2006, which Baker said he supports. Moreover, the state legislature remains in the hands of Democrats.
In Maryland, newly elected Republican Gov. Larry Hogan has not voiced a clear plan for the future of the expanded Medicaid program, which has already covered about 377,000 previously uninsured state residents. The Medicaid expansion wasn’t a notable issue during Hogan’s gubernatorial campaign, and he faces a Democratic-led state legislature in a traditionally blue state. In an October interview with the Washington Times, Hogan seemed to indicate that he won’t pick a fight over Medicaid, saying it would be a “fools errand” to do so. “We’re going to try to win the battles we can win. That’s tough enough as it is,” Hogan told the Times.
Things look safer for the future of the expanded Medicaid program established in Illinois, where newly elected Republican governor Bruce Rauner of Illinois has made clear his position on the state’s Medicaid expansion, which has covered nearly 470,000 people: He’s not going to fight the Democratic-controlled legislature over it, even though he wouldn’t have adopted it in the first place. “I would not have accepted expansion of Medicaid,” Rauner said. “It’s been done now and I’m not advocating a rollback. But what I am advocating and always have and always will is we’ve got to restructure Medicaid in Illinois…”
Consequences of rejecting the Medicaid expansion
The Affordable Care Act always intended the Medicaid expansion to be a national program that would extend coverage to those who earns up to 133 percent of the federal poverty level — or about $15,300 for a single person. But the Supreme Court ruling and resistance from Republican policymakers have shortened its reach, leaving the poorest uninsured Americans with no coverage. Because Congress didn’t anticipate Medicaid wouldn’t be available to everyone with earnings below poverty, tax credits for private insurance only are available to people who make more than that, which is about $11,500 for a single person.
With many states opting not to implement the Medicaid expansion, millions of low-income adults will remain outside the reach of the Affordable Care Act and continue to have limited, if any, option for health coverage: most do not have access to employer-based coverage through a job, few can afford coverage on their own, and most are currently ineligible for public coverage in their state. People in the coverage gap are likely to face barriers to needed health services or, if they do require medical care, potentially serious financial consequences. Further, the safety net of clinics and hospitals that has traditionally served the uninsured population will continue to be stretched in these these states as the costs of uncompensated care remain high.
As it stands, nearly five million poor adults in states not expanding Medicaid coverage will be ineligible for assistance, while 17 million others who earn more than they do will be eligible for tax credits to help them pay for coverage in the new insurance Marketplaces. With attention focused on the politics of the law, it is important not to forget the people who are affected by these decisions and the impact it could have on their lives. Residents of non-expansion states have poorer health to begin with — a disparity that experts say will only grow wider as residents of healthier states gain coverage while those in unhealthy states remain shut out.
According to a study conducted by the Commonwealth Fund, the decision by some GOP legislators to refuse to expand Medicaid could set states on radically different trajectories, with some enjoying progressively better health and health care and others falling further and further behind. This could also have significant social and economic implications, as the health of the state population is inextricably tied to economic stability and growth as well as social factors like crime and recidivism rates. And for many, the decision could have life-or-death implications: according to a Harvard study published last January, as many as 17,000 uninsured Americans will die directly as a result of Republican lawmakers’ rejection of the Medicaid expansion.
Despite losses in those five key states where an estimated 5 million low-income Americans will likely be left uninsured, expansion advocates say they are not giving up and will continue to push GOP lawmakers to accept the federally-funded expansion. Meanwhile, HHS Secretary Sylvia Mathews Burwell on Tuesday said Medicaid expansion would remain among her “top priorities” and urged newly elected governors to contact her if they are interested in expanding their states’ Medicaid programs, The Hill reports. During a speech to the National Association of Medicaid Directors, Burwell said HHS is “eager and willing to work with states that have yet to expand.” She added, “My message to governors is that, ‘If you’re interested in expanding, call me.’ And to those governors who are about to get elected or re-elected today, my message is that ‘I’m happy to meet with you before your inauguration.'”
Already, nine Republican governors have expanded their Medicaid programs, including a few who easily won re-election last night. And Medicaid expansion has support from hospitals, which hold considerable political clout and have a lot to lose without the infusion of federal funds from the expansion. Expansion advocates are hopeful they can gain ground in states like Utah, whose Republican governor hopes to take a plan to the GOP-controlled legislature, and Wyoming, where Gov. Matt Mead, also a Republican, has expressed interest in widening eligibility for Medicaid. Indiana is also negotiating with the Obama administration to expand Medicaid. Republican governors in Tennessee, Wyoming, South Dakota and North Carolina have all also suggested they would consider Medicaid expansion plans in 2015.