In a disappointing committee vote yesterday Tennessee Governor Bill Haslam’s carefully crafted state-specific plan for using federal Medicaid expansion dollars was rejected. A state budget cost-neutral financing mechanism through hospital fees and multiple other provisions that would have made the plan a significant showcase of conservative health policy ideas were not enough to obtain legislative approval in Tennessee’s special session. The defeat contrasts with Indiana’s recent implementation of Governor Mike Pence’s plan for expansion – a plan that had widespread institutional and political support in the state.
Mirroring the talk in Indiana and Tennessee, ongoing expansion discussions among Republicans are taking place at the moment in Wyoming and Utah. Utah is starting full debate while Wyoming’s path is looking increasingly rocky as Gregory Nickerson’s reporting at wyofile.com from Cheyenne makes abundantly clear. [Note: The Wyoming bill failed Feb. 6 in the WY Senate.] A serious but lower level of discussion around the issue continues in Alaska, Montana, Idaho, Nebraska and even Florida.
These recent developments in the Medicaid expansion debate across the states suggest some broad themes:
This is a tough debate among Republicans. Tennessee Governor Haslam had very high public approval ratings, a recent resoundingly successful election and backing from his state’s business, provider and faith communities. Public backing of his Tennessee-style Medicaid plan was high and featured conservative personal responsibility requirements, budget neutrality for the state and clear opt-out provisions should the federal government ever not meet its financing promises. In addition the plan took advantage of the “use it or lose it” billions in federal financing available that has been earmarked specifically for the state. All this policy pragmatism however couldn’t compete with the political reality that some state legislators were simply not going to support any plan for expanded health coverage using federal Medicaid dollars no matter what form it took.
Governors who want to enact a their own plan for extending health coverage using federal Medicaid dollars can’t just present a plan; they need to be willing to expend considerable political capital over a substantial period of time to get it passed. For example, Indiana’s Governor Pence built on the groundwork laid by his predecessor Governor Mitch Daniels who had secured a Medicaid waiver to create Healthy Indiana. The waiver was in place prior to passage of the Affordable Care Act and makes use of health savings accounts, personal responsibility requirements and other cost saving measures. This allowed Pence to present use of the new federal Medicaid expansion dollars as an extension of current conservative reforms. Contrast this with Tennessee’s Haslam who travelled the state building public support for his plan and worked directly with key lawmakers but had a very short time frame for success after public announcement of his plan. And early on in the debate, Haslam seemed not to realize the magnitude of the task to persuade skeptical members of his own party.
Over in Utah, Governor Gary Herbert presented a plan with broad support and many of the same features as eventually proposed in Tennessee. However, he decided against a special session and took a longer view of the need to work with skeptical members in the legislature during the current regular legislative session. As a result, while Herbert’s plan has hit some major speed bumps, no one is counting it out yet. The other state with a current active discussion on Medicaid expansion – Wyoming – showcases a strong initial plan and strong initial engagement by Governor Matt Mead. However Governor Mead hasn’t been very publically supportive since. As a result Wyoming’s efforts are limping along currently and prospects are dimming for passage of a bill this year. And to round out this list, Governor Rick Scott of Florida early on announced his support for a Medicaid expansion plan in his state but “faded” after his initial big announcement. Although current discussions are underway in Florida, the Governor has yet to step into a more active role. The message of these varying strategies and results is that success at this issue takes lots of hard political work.
Overall, efforts to expand coverage to poor people through Medicaid are popular across the political spectrum as long as the plan is constructed as a “state solution.” This theme showcases the common disconnect between a state governor, who has to run and appeal to voters across the state and members of a state legislature who have to appeal and run to people in their very different districts and face primary challenges from much further to the right. Popular governors leading the way in conservative states on presenting alternative plans for Medicaid expansion are hitting consistent themes that resonate. The overall message from governors is that they are taking the Medicaid money and crafting a state-based solution to expanding coverage that works for their state. This isn’t just empty political talk. The federal government is willing to make significant concessions in how Medicaid programs are run in order to encourage states to craft state plans. Governors are also highlighting the high percentage of working people in the newly Medicaid eligible population. In addition, state executives are more carefully crafting plans to make clear how their state’s share will be paid for – in many cases, hospital fees – in order to answer worries about the eventual 10% state share of expenses. Inclusion of these elements has allowed governors to gain impressive support from providers, the faith community, businesses and the public at large. Editorial support from media across the spectrum in these states has been more the norm than the exception. I can think of few issues concerning health care for low-income people in the last twenty years that have attracted this level of bipartisan support.
However, broad support and federal flexibility are only two legs of the stool needed for passage – political considerations that play well not only statewide but in very, very conservative districts are absolutely key as well and at least for some legislators in these states this broad support has not translated into support for the state-crafted plans. One particular fear is of primary challenges driven by a small minority of even more conservative voters and special interests who are opposed to any Medicaid expansion whatsoever.
The trend still is toward more states expanding Medicaid, but it isn’t going to be an easy debate. It may be obvious, but like any major policy change at the state level there really isn’t any substitute for hard work. With Indiana, now 29 states (including DC) have adopted various Medicaid expansion plans so the trend is clearly towards expansion. And current governors entering into the Medicaid discussion whether or not their plans are enacted are paving the way for future debate. They’ve crafted state-based plans to use the Medicaid funding that make significant changes to appeal to voters in more conservative states. They’ve addressed concerns about state’s eventual 10% share of financing and have employed a variety of opt-out or pilot program strategies to meet the challenge of questions about the federal government’s continuing role. Overall they have obtained significant concessions from the federal government as to operations of Medicaid plans. Governors are now drawing a detailed roadmap on moving Medicaid expansion forward. It’s just becoming clear there are no easy shortcuts.
