Rural Health Policy Project

Medicaid Expansion Debate: A New Phase

Across the states, moving towards an election year typically means a retreat from policymakers wanting to take on major issues of interest to their constituents for fear of offending one side or the other. In an era of increasing “constant campaigns” rather than actual governance, this can mean even more legislative paralysis. But health care – and Medicaid – have become such pressing issues perhaps this rule of thumb has fallen by the wayside.  A survey of the debate in the states still refusing federal funding available for Medicaid expansion reveals some surprises.

Medicaid expansion is a major issue in the Mississippi governor’s race – where the popular Jim Hood (D), the state attorney general with a convincing track record of winning races in this very conservative state, has made it a centerpiece of his campaign.  And the candidates have been running neck and neck.  Previous Governor’s races like this in North Carolina, Kansas, and Wisconsin have put chief executives in office who have prioritized Medicaid expansion in the states.  So far legislators in these states have dug in, still resisting expansion. But pressure is building and Mississippi’s Hood sees expansion as an issue worth running – and winning on.

In North Carolina, where the legislature is still in session and still considering Medicaid expansion, conservative voices are growing.  In rural, conservative Graham county, Republican County Commissioner Dale Wiggins was scathing in a letter to NC GOP Senate leader Phil Berger:

“Here in Graham County, Senator, we are accustomed to being ignored by not only the governor but by our legislature as well,” Wiggins wrote. “We supported Medicaid expansion because our citizens need it. Did you know Senator that our poverty level is near 30%?”

A GOP-backed bill is sitting in the NC House currently awaiting a vote. While NC’s Governor continues to talk affordable health coverage through Medicaid at every opportunity, pressure across the state from Republicans for compromise builds.

In Oklahoma, a push to add Medicaid expansion as a ballot issue to put before the voters is gaining steam and legislators and the Governor are debating what to do in response.  Tellingly, discussion so far has centered on how to develop an alternative expansion plan to defuse the momentum for a vote, not how to block more affordable coverage. The conservative former GOP Speaker of the Oklahoma House, Kris Steele, came out strongly recently in favor of expansion, another signal of a slow shift in the political climate.

This year in Kansas, the new Governor Laura Kelly was able to work with her conservative legislature to get major changes in taxes and funding for education. Despite an intense push for Medicaid expansion by her administration, a compromise wasn’t reached before then end of the legislative session. But a new Medicaid council, a rural listening tour, and her own statements show Kelly and the Medicaid issue aren’t going anywhere.

While the debate seems to be stalled by election year politics in many other states, the persistence of Medicaid expansion points to the importance of the health care issue.  For example, rural hospitals continue to close.  In fact, 12 of the 17 rural hospitals that have closed in 2019 were in states still refusing the Medicaid expansion.  Each of these closings reverberates throughout their communities, with the loss of access to care, jobs, and economic security.  A recent study suggests even overall mortality rates rise as a result of some hospital closures. And Medicaid expansion plays a key role in hospital financial health.

In addition, the longtime national maternal mortality crisis is finally becoming a high-profile issue. We reviewed the research on the linkages between maternal health and Medicaid expansion in our comprehensive report from earlier this year. More coverage for women of childbearing age is recognized as a key component to making sure mothers get quality care as we start to reduce the embarrassing racial inequities in this measure of health and our moral obligations.

Finally, huge shifts in cost sharing for employer plans are driving home to many people just how fragile our employer system of coverage for over 180 million Americans can be. When the out-of-pocket cost of medical care with a high deductible plan can easily top over $6,000 for someone with good employer health coverage, the appeal of a public plan becomes more apparent to more people.

While policymakers in some non-expansion states like Florida, Texas, or Wisconsin may continue to resist, the persistence of Medicaid expansion as an issue shows they will have to deal with their constituents’ desire for more affordable health coverage sooner rather than later.

Adam Searing is an Associate Professor at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.