As the midterm elections draw near, carefully sifting through the mountains of third-party attack advertising, talking point driven rhetoric and overwhelming horse race polling brings out a nugget of information regarding Medicaid expansion under the Affordable Care Act. Surprisingly, in some states that have yet to accept the federal money to cover more uninsured people under their Medicaid programs, selected conservative politicians are sounding significantly more positive notes on Medicaid.

One has to be cautious when looking at this trend. Public policy researchers – with good reason – are often skeptical of the effect of campaign promises and language as a signal of major shifts on a specific issue [Kingdon 2011].   Nevertheless, a remarkable change in language and even approach towards Medicaid expansion has been occurring in some states around the country and on an issue this well defined it is worth noting. After all, political leaders can and do make vague promises but with federal money on the table and Medicaid expansion coverage plans already in place in a majority of states, even the most reluctant politician has to define a position.

Typical this week is Missouri Republican state Senator Ryan Silvey who told the Kansas City Business Journal he thought his state should expand Medicaid to help protect hospitals. Missouri blocked expansion this year, but Silvey thinks legislators may act to expand in 2015.

Then there’s North Carolina where Republican Governor Pat McCrory told a group of CEOs at a meeting this week he is weighing Medicaid expansion for the state. Also note in North Carolina’s tight race for US Senate, GOP candidate (and former Republican House Speaker) Thom Tillis had this to say this week:

 “So, I would encourage the state legislature and the governor to consider it [Medicaid expansion] if they’re completely convinced that we’ve now got the situation under control.”

This is the same Thom Tillis who earlier in the year (admittedly during the usual move toward the ideological base in the party primaries) boasted on his campaign’s website that: “Under Tillis’ leadership, North Carolina has refused Obamacare’s Medicaid expansion.”

Turning west, Wyoming Republican Governor Matt Mead is being criticized by opponents for his decision last year not to accept Medicaid expansion funds. However, he has been meeting with federal officials to see if any compromise is possible to expand coverage in his state. He’s still “skeptical” but said in a recent debate he is searching for solutions.

In Montana, a Q&A with state House Republican Greg Hertz is revealing. While Hertz responds he isn’t in support of expanding Medicaid “until it can be reformed” he then goes to list how Montana should request waivers from the federal government to expand coverage to the uninsured in a process much like is currently going on in Utah.

And speaking of Utah, Republican Governor Gary Herbert is the most prominent example of this trend where he announced this week that he had a deal – although no details were forthcoming – with the federal government on his alternative plan to take the federal Medicaid money and extend coverage to the uninsured for his own plan.

So, around the country, despite all the overwhelming political advertising, issues like Medicaid are actually being discussed during the campaign season. For some politicians, views seem to be changing. Several factors are combining to drive this trend:

1. There is consistent majority support among state voters for accepting the federal Medicaid money to expand coverage to low income people. Even in Mississippi – a state featured this week in an excellent article by Sarah Varney as a poster child for resistance to the health law – a majority of voters support expansion. In Utah, 88% of voters support Governor Herbert’s state-crafted plan to use Medicaid expansion dollars to expand coverage – including 64% of Republicans. Even in states continuing to strongly resist expansion like Virginia and Wisconsin, majorities of voters statewide support using the federal money. And over half the public in Arkansas, North Carolina and Louisiana supports Medicaid expansion.

 2. The cost of refusing to take the Medicaid money to expand coverage is clear. Thanks to reliable and detailed reports from the Urban Institute and the Robert Wood Johnson Foundation the costs to state that don’t accept the expansion dollars, especially to rural areas, are widely reported and well-known. And the adverse effect on rural hospitals of refusing the Medicaid money is becoming clearer every day.

 3. Politicians are repeatedly getting asked about this issue leading up to the election. In looking at the reporting around the country on debates, candidate questionnaires and similar areas there is a subtle but notable effect. The questions speak not only to public interest but also to the willingness of Democrats to press Republicans on the Medicaid expansion issue. For example, Medicaid was a main question in the recent Wyoming gubernatorial debate. And in Montana, a Missoula area state House and Senate candidate forum focused on the expansion issue. Issue-driven media coverage often highlights Medicaid, especially in candidate profiles. Typical of profile questionnaires, in one Maine paper the question whether or not a candidate supports Medicaid expansion comes first, even if in this case Democrats and Republicans split into more predictable lines on their answers. In tight races like Wisconsin’s contest for Governor, incumbent Scott Walker is regularly attacked by his opponent, executive Mary Burke, on Medicaid expansion.

4.  This trend reflects the fading of the Affordable Care Act overall as a major issue in the current election cycle. Increasingly, talking about whether or not to expand Medicaid is seen as a more immediate issue than the health care law overall.  Drew Altman of the Kaiser Family Foundation put it best in the Wall Street Journal this week:

 “Last fall, with the HealthCare.gov rollout making headlines, it was reasonable to think the Affordable Care Act might be a big issue in the midterms. But a year later, with implementation moving much more smoothly, the health-care law does not appear to be much of a vote-mover. When asked to choose the most important issue to their vote in the upcoming midterm election, just 8% of registered voters picked the health-care law in October Kaiser Family Foundation polling.”

 I’ve been listening to many people around the country on the Medicaid issue, and without the ideologically driven debate that marked the health law, unsurprisingly most voters across the political spectrum are willing to consider compromise solutions that would allow their state to accept federal dollars and extend health coverage to low income people.

So, while change among Republicans is certainly not consistent – there are plenty of states and politicians who continue to resist any talk of accepting Medicaid dollars even for a state-crafted expansion plan – it is clear that significant change is happening. After the election, expect the most substantial moves forward on the Medicaid expansion issue in Utah and North Carolina and then on to other states like Idaho, Nebraska, Wyoming or Montana.  Also expect to see more plans to expand that allow Republican governors and other leaders to design their own state programs using federal Medicaid dollars. This has already happened in Pennsylvania, Arkansas, and Iowa and has started to happen in Utah.

These alternatives to traditional Medicaid produced through state negotiations with the federal government will allow Republican leaders to extend coverage to low income uninsured people in ways they see as reforming current Medicaid programs along more conservative lines. They will also allow politicians to answer their critics, address the costs to their hospitals and constituents and respond to a public that sees a need to cover uninsured people in their states.