The States Where Obamacare's Footprint Might Get Even Bigger

Now that the Affordable Care Act has survived its most serious threat in Congress, the law’s footprint across the country might grow even larger in the months ahead.

Several states that initially opted out of Obamacare’s Medicaid expansion are now reconsidering their decision as a result of last year’s elections and as Republicans come under new pressure to accept the billions in federal dollars available under the law. The most aggressive push is coming in deep-red Kansas, where the Republican-controlled Senate on Tuesday sent Governor Sam Brownback legislation that could expand the state’s version of Medicaid to as many as 150,000 new enrollees.

Brownback has criticized the bill and has 10 days to veto it, but a coalition of moderate Republicans and Democrats in the legislature are only a few votes shy of the threshold needed for an override. In Georgia, GOP Governor Nathan Deal said Monday that following the failure of the American Health Care Act on Capitol Hill last week, the state would explore seeking waivers from the Trump administration to allow Georgia to access federal money for an expansion while implementing restrictions on eligibility for enrollees. Utah has also sought waivers for a limited expansion approved last year by its state legislature. And in Maine, advocates for expanding Medicaid successfully forced the issue onto the ballot as a referendum this November; they did so after falling a few votes short of overriding conservative Governor Paul LePage’s repeated vetoes of expansion legislation.

Longer-shot efforts are under way in Virginia and North Carolina, where Democratic Governors Terry McAuliffe and Roy Cooper are battling Republican legislatures opposed to expanding the program, which provides health-care coverage for the poor and disabled. McAuliffe has seized on the defeat of the repeal effort to renew a years-long expansion campaign in Virginia, but Republican legislators have thus far been unmoved, The Washington Post reported. “There are no excuses anymore,” the governor said Monday.

The Affordable Care Act originally expanded Medicaid to households living just above the poverty line under a system in which the federal government would cover all of the costs through 2016. After that, states would begin chipping in a percentage of the bill. But the Supreme Court in 2012 ruled that states could choose not to accept the federal money, and as a result, 19 states either wholly or partially controlled by Republicans did not expand Medicaid.

A number of factors have contributed to the new momentum for Medicaid expansion. In North Carolina, Cooper’s defeat of GOP incumbent Pat McCrory restarted the debate over the program. And in Kansas, a lengthy and ongoing budget crisis prompted an electoral backlash against Brownback, ushering a wave of Democrats and moderate Republicans into the state legislature who argued for taking the federal money as a means of boosting the local economy and relieving some of the strain on the budget. “It generates economic activity,” said Dee Mahan, director of Medicaid initiatives at Families USA, a nonprofit health-advocacy organization. “This is money that is going to pay hospitals for care provided, pay doctors, nurses, community-health centers, other health-care providers who are otherwise not being paid for that care or being paid only through state funds.”

Alliance for a Healthy Kansas, a group pushing for expansion, estimates that the state has rejected nearly $1.8 billion in federal aid. Initially, the legislature began moving a bill to join the expansion out of fear that Republicans in Congress would freeze the program when they repealed Obamacare. “People really were trying to move before anything happened in D.C., so that our interests were protected,” said David Jordan, the Alliance’s executive director. “People understood that there was some urgency.”

Largely as a response to Kansas’s push, conservatives in the U.S. House demanded that GOP leaders add a provision to the repeal bill that would block new states from expanding Medicaid. But the legislation’s collapse last week cleared that path for Kansas and other states. Top Republicans in the House said Tuesday they had not given up on repealing Obamacare, but Sean Spicer, the White House press secretary, conceded there was no specific strategy to revive the effort. “We’re much better served by getting in under the wire than being left behind, than being one of the have-not states,” Jordan said.

Brownback, however, hasn’t budged in his opposition. “To expand Obamacare when the program is in a death spiral is not responsible policy,” said Melika Willoughby, the governor’s spokeswoman. “Kansas must prioritize the care and service of vulnerable Kansans, addressing their health-care needs in a sustainable way, not expanding a failing entitlement program to able-bodied adults.” Willoughby wouldn’t say whether Brownback was definitely intent on vetoing the bill passed by the Senate, but the expansion’s best shot in Kansas may rest on the governor’s career prospects: He has reportedly been under consideration for an appointment by President Trump to a U.N. mission in Rome.

As in Kansas, the biggest challenge for advocates in Maine is a conservative governor adamantly opposed to expansion. LePage has vetoed Medicaid legislation five times, and he endorsed the AHCA in Congress only after Republicans agreed to language that would allow states to implement work requirements for Medicaid enrollees. Expansion has gained support in Maine as the state’s opioid crisis has deepened, but the votes to force it through in the legislature are still not there. “People have been pretty dug in over the last several years,” said Emily Brostek, executive director of the Maine-based Consumers for Affordable Health Care. “I would suspect that if it’s going to happen in Maine, it’s probably going to be through this referendum effort, at least over the next year.”

The success of the program in other Republican-led states has also helped influence the debate in states that did not initially expand Medicaid. GOP Governors John Kasich of Ohio and Rick Snyder of Michigan have taken credit for the drop in the uninsured rate in their states as a result of the expansion, and advocates have pointed to studies showing better economic results in states that accepted the federal money. “There are states that are looking around at the states that are surrounding them that are doing better because they have expanded, and that’s certainly a pressure,” Mahan said.

The argument from conservatives has been that states shouldn’t rush to join a collapsing federal health law that a new Congress is bent on repealing. But Obamacare’s biggest challenge has been the stability of its individual-market insurance exchanges, not the Medicaid system. And with repeal looking less and less likely, the allure of federal aid may be too much even for Republicans to resist. In the end, the most tangible result of an election dominated by Republicans might be an expansion of the very law they love to hate.