Last week the New York Times editorialized on “The Fate of Medicaid Expansion” arguing that such efforts had “suffered a blow in the midterm elections” and that the odds for expansion “have grown longer.” The Times was echoing a general strain of conventional wisdom since the midterms following the reelection of governors who are expansion opponents in states like Maine, Florida and Wisconsin which meant the apparent end of immediate Medicaid expansion prospects in those states. In addition, the election of a new Arkansas governor whose support for the state’s very successful – but subject to a difficult budget renewal process – expansion “Private Option” plan put that state’s stance on Medicaid in some jeopardy.
While these are certainly valid points, I think overall this is a pretty pessimistic view. One doesn’t have to look very far for more information. Even on the day following the midterms a well-researched Politico story by Rachana Pradhan and Sarah Wheaton detailed the moves forward on expansion in some states despite the election losses – and despite the headline noting that “GOP victories blunt hopes of Medicaid expansion.” Before the election I wrote about this trend and the reasons driving it in key states around the country out of the mainstream political spotlight. After the midterms my colleague Joan Alker laid out her detailed take on what the midterms meant for Medicaid. A quote this week from Matt Salo, Director of the National Association of Medicaid Directors in an NPR interview sums this view up:
“I think it’s probably hard to say that the prospects for expansion are better post-election, but I’m not sure that they’re necessarily worse off either, I think that they’re just different.”
And to bear this out, since the midterms there has been plenty of movement over the past couple of weeks in several states, especially those where there were fewer high-profile and highly partisan midterm political races, on the subject of accepting the federal Medicaid expansion money:
In Alaska, Governor-elect Walker’s victory put discussion of the expansion in play, although the idea, like in most states, definitely faces a significant debate.
In North Carolina, an overview of the prospects for expansion puts them in a positive light with Republican Governor Pat McCrory intent on putting forth a plan for expansion in a state Medicaid program he says he has already stabilized, improved and wishes to reform even more. McCrory just days after the midterms said he was interested in an expansion waiver plan like those being considered or implemented in Indiana, Pennsylvania and Utah. Of course, NC legislative opponents are already voicing concern, but any Republican governor will face similar dissent.
Montana’s Governor Steve Bullock unveiled his plan this week to use the federal dollars for Medicaid expansion through a combination of purchase of private health plans and bidding of private insurance contractors to administer the program. Bullock bills his “Healthy Montana Plan” as Medicaid reform for cost control and quality improvement modeled on Montana’s successful and popular children’s health insurance program.
Of course in Utah, the state furthest along this road, Governor Gary Herbert says he will share his “Healthy Utah Plan” – the details of which still are not yet public – with Utah lawmakers on December 4. One of the nation’s most popular governors, Herbert has been negotiating with the federal government around the outlines of his plan for months and believes he has created a proposal to use the federal Medicaid dollars in his state in a way that makes significant Medicaid reforms.
In Wyoming, Governor Matt Mead announced after the election that he was working closely with the federal government to try and craft a plan for using the federal Medicaid dollars that would contain significant new reforms and requirements designed to change the program and make legislative approval more likely.
And finally, in Idaho just yesterday three of four Republican legislators serving on an Idaho work group tasked by Governor C.L. “Butch” Otter to study and recommend proposals for Idaho to use the federal Medicaid dollars joined in approving a proposal that uses a joint private insurer/public program approach. The facilitator for the group said the proposal was an attempt to “figure out something that will work out not just practically but also politically.”
Obviously expansion prospects in any of these states face debate and skepticism from conservative legislatures. But that was true before the midterms. Ultimately the financial reasons that underlie state expansion decisions remain and are only getting more prominent. Rural hospitals and hospitals serving high numbers of uninsured patients are under significant strain. Gaps remain in the health care safety net. And money, plus a functioning alternative now proven in twenty-eight states, is available. Although even more political (not practical) barriers loom on the horizon in the form of federal budget debates and the King v. Burwell case on tax credit subsidies under the Affordable Care Act, I think the concerns of Washington, DC will play a back seat for now in these states to the immediate needs of people, hospitals, and state budgets. In addition, many Governors are finding that substantial Medicaid reform through federal government concessions is possible as a part of expansion. This means states can create their own unique programs to use the Medicaid money and no state’s chief executive likes to turn down the chance of implementing a signature plan that may be remembered for years to come. Overall I think in many ways the debate around Medicaid expansion dollars is maturing from a discussion filled with political posturing and election-related overtones to a more measured conversation about state health needs and state health problems. Sure, politics is always going to play a part, but at least for now there seems to be movement in a significant number of states towards more pragmatic proposals.
