While the ultimate outcome for the GOP health care bill is unclear here in Washington, the uncertainty created by the legislation is already having an adverse effect on attempts to expand coverage in four states. Idaho, Georgia, Tennessee, and Kansas all have had robust discussions over the past year about joining the other 32 states using federal funding under the Affordable Care Act (ACA) to expand Medicaid for low-income adults who aren’t making enough to qualify for federal tax subsidies to buy insurance through the ACA. In all but Kansas, these discussions among state-level Republican lawmakers have ground to a halt as Congressional Republicans in Washington discuss ending the Medicaid expansion as part of their proposed American Health Care Act (AHCA). And while the effort in Kansas is still moving forward, serious doubts remain.
What’s driving this is pretty simple – the Congressional Budget Office analysis of the AHCA anticipates $880 billion in federal cuts for state Medicaid funding. These cuts are a combination of the provisions instituting per capita funding caps fundamentally changing the financing structure of the Medicaid program and the elimination of additional federal funding for the states that have already expanded their Medicaid programs. Amendments to the bill proposed this week would accelerate these changes and further attack the structure of Medicaid. Substantial opposition to such huge Medicaid cuts is coming from state Governors of both political parties but, at least in these four states, just the fact of these proposals being on the table is already being felt. With the reality that that they might have to absorb huge federal funding cuts in Medicaid, the largest source of federal funding flowing into their state budgets, lawmakers are having second thoughts.
The one bright spot here is Kansas where a strong bipartisan group of lawmakers has been moving forward to address Medicaid expansion despite the uncertainty. Even a potential veto on the bill from the Governor was seen as likely to be overridden. However, Republican lawmakers in Kansas got unwelcome news from Republican lawmakers in Washington this week when Congressional leaders proposed an amendment to the health care bill that would eliminate additional funding for all states who have not yet expanded Medicaid as of March 1, 2017. This would mean that the efforts in Kansas to close the gap would effectively be null and void.
In Idaho, lawmakers have shifted from moving quickly forward on dealing with the problem of the Medicaid gap back to a focus on the reliable old solution for people who don’t want to address the actual costs of modern surgery, cancer treatment and so on – improving primary care. While always a worthy goal, closing the Medicaid health coverage gap is “Likely not this year” according to a key lawmaker. And even through a recent poll found that 75% of Georgia voters support Medicaid expansion, recent headlines read: “In spite of support, Medicaid expansion in Georgia remains unlikely.” Disappointing in a state that many observers expected to make significant moves in 2017 towards addressing Medicaid expansion. And over in Tennessee lots of discussion among Governor Haslam and Republican lawmakers around what was forming up to be a concrete solution to move forward and address the health care needs of people in the health gap has foundered with the new uncertainty.
Overall, the dynamic in these states shows a huge disconnect between what’s happening in Congress right now and – at least some – state lawmakers. In all four of these states, strong constituent pressure hasn’t been on “repeal” but rather on trying to find a solution for people left behind when some states decided not to expand Medicaid under the Affordable Care Act. Uncertainty in Washington makes it harder for these state lawmakers to act now, but the need for health coverage that has been driving the discussions on closing the coverage gap in these very conservative states isn’t going away regardless of what happens with the health care bill currently in Congress.