Pennsylvania’s recent decision to expand Medicaid as part of the Affordable Care Act (ACA) brings the total number of states doing so to 27 (plus Washington, D.C.). This leaves 23 states continuing to resist expanding Medicaid, resulting in a coverage gap affecting 4.5 million Americans. They are too poor to receive help to purchase private insurance on an exchange but not poor enough to qualify for Medicaid. Many ardent opponents among state leaders are retiring or are up for re-election this November, including in states with large coverage gaps such as Texas, Florida and Georgia. Supporters of the ACA are hoping that elections in these states will open the door to more people receiving insurance coverage through Medicaid. What are the chances?
Governors are being selected in 22 states currently led by Republicans. One-third of these have already expanded Medicaid (Arizona, Iowa, Michigan, New Mexico, Nevada, Ohio and Pennsylvania). Barack Obama won all but one of these states in 2008 and 2012. Accepting the expansion was a way for these governors to appeal to voters on the other side of the aisle while also reducing the number of uninsured residents in their states and bringing millions of dollars to local hospitals and businesses.
Florida, Maine and Wisconsin are the only remaining states with gubernatorial elections this year that voted for Obama, are led by a Republican and have not expanded Medicaid. These three states are the most likely to reverse course on the ACA, not because the Republican incumbents are trying to appeal to moderates by expanding Medicaid but because the governors’ mansions are the most likely to flip control. All three races are considered toss-ups, with Democrats currently slightly favored in Florida and Maine. Democrats may win gubernatorial races other states, but stronger legislative opposition makes it less likely that they will expand Medicaid.
Rick Scott became Florida’s governor in 2010 after winning by just 68,000 votes, or a little more than 1 percent. He rejected building a state-run insurance exchange but ultimately supported expanding Medicaid. He tried to appease conservatives calling him a traitor by clarifying that his support is only for the three years in which the federal government will pay for the full expansion. He wasn’t expanding Medicaid per se — just not stopping the federal government from doing so. Progressives subsequently accused him of doing little more than offering lip service.
Scott’s opponent in 2014 is Charlie Crist, who has his own complicated past. From 2007 to 2011 he was Florida’s Republican governor. He left the Republican Party to (unsuccessfully) challenge Marco Rubio in the state’s 2010 Senate race. In 2012 he became a Democrat and endorsed Obama’s re-election. Crist is making Medicaid expansion a major focus of his campaign. He points to estimates that the expansion would bring more than $51 billion to the state. According to the Kaiser Family Foundation, nearly half a million Floridians would be eligible for Medicaid under the ACA.
A victory for Crist would not guarantee Medicaid expansion in Florida. Gov. Terry McAuliffe’s failure in Virginia is a reminder of the ability of state legislatures to block a governor. Republicans in the Florida House already killed a bill supported by Scott that would have allowed people eligible for the Medicaid expansion to use federal funds to purchase private insurance through the exchange. Crist points out that the Florida legislature is about to have a new house speaker who will be more open to this issue and that he will do whatever it takes to push it through.
I predict that Crist will win narrowly but that Medicaid expansion will not come easily.
When the Supreme Court made Medicaid expansion optional in 2012, the prevailing wisdom was that every state would ultimately move forward. But nearly half the states still oppose it.
Maine is the only New England state that has not yet expanded Medicaid. The only barrier is the opposition of Gov. Paul LePage, who says that expanding Medicaid would be “sinful” and “ruinous” for the state budget. He vetoed five expansion bills passed with bipartisan support by the legislature. Attempts to override his vetoes fell a few votes short.
LePage is one of the most unpopular governors in the nation, with recent polls showing that more than half the state’s voters want him out of office. Even so, he trails Democratic challenger Mike Michaud by just 1 percentage point. Third-party candidate Eliot Cutler may split the anti-LePage vote enough to help him win re-election. Both Michaud and Cutler support Medicaid expansion and are making it a major focus of their campaigns. They point to reports estimating that expansion would cover up to 70,000 people and bring 3,100 jobs and $350 million in economic activity to the state.
I predict that Michaud wins and successfully expands Medicaid in 2015.
Scott Walker is on the ballot for the third time in four years. He won his initial gubernatorial election by 6 percentage points in 2010 and then survived a contentious recall election by nearly the same margin in 2012. Opposing the ACA has been a major issue in all three campaigns.
Under pressure from tea party conservatives during his 2012 recall campaign, he returned a $38 million grant to the Obama administration that would have made Wisconsin one of the leaders in developing an insurance exchange. He later rejected the Medicaid expansion, saying he did not trust the federal government to fulfill its promises down the road.
However, unlike Republicans in other states, he did partially expand Medicaid. Since the expansion was not fully compliant with the ACA, much of it was paid for with state dollars rather than by the federal government. A nonpartisan analysis (PDF) in August 2014 estimated that the state missed out on $500 million over five years by not fully expanding Medicaid.
Walker’s challenger, Mary Burke, supports full expansion. Recent polls give Walker a slight edge. Even if Burke wins, it may be difficult to expand Medicaid unless a significant number of seats in the legislature also flip control. She may be able to take steps to expand Medicaid on her own, though it is unclear how much she is willing to do unilaterally.
I predict that Walker will narrowly win re-election and Wisconsin will not expand Medicaid in the near term.
Other states to watch
Republicans are running in surprisingly close races in other states, such as Georgia and Kansas. However, even if Govs. Nathan Deal, R-Ga., and Sam Brownback, R-Kans., lose, it is highly unlikely that the conservative legislators in their states will pass a bill expanding Medicaid. These legislatures even took the unusual step of pre-emptively barring future governors from expanding Medicaid without legislative approval, just in case a Democrat is elected in 2014.
Texas has most people who would stand to benefit from Medicaid expansion. Democrat Wendy Davis supports expansion but is not likely to defeat Republican Greg Abbott, who opposes it. (Gov. Rick Perry is not seeking election for a fourth term.)
Every state currently led by Democrats that is on the ballot in 2014 has already expanded Medicaid. However, a change in power could make the program vulnerable in Arkansas. After intense pressure from Democratic Gov. Mike Beebe, who is term-limited this year, the state used a waiver from the Obama administration to expand Medicaid under the so-called private option. The program’s renewal failed four times in early 2014 because state law requires a minimum of three-fourths of legislators in each chamber to pass spending bills. Recent polls have the race leaning to Republican Asa Hutchinson, who is a strong opponent of the ACA but has remained circumspect about the private option. It is unclear how a change in power would affect whether enough votes could be secured again in 2015 to keep the program going.
When the Supreme Court made Medicaid expansion optional in June 2012, the prevailing wisdom was that every state would ultimately adopt it; even if some opposed it for a few months in the hopes that Mitt Romney would be elected president, there was too much money available for them to resist forever. Since then, more states have accepted the expansion, but nearly half still oppose it.
A growing number of Republicans are using waivers from the Obama administration to take ACA money for expanding coverage while saying they oppose “Obamacare.” But the path to full expansion across the country remains remarkably narrow. Despite hopes of supporters of the ACA, the 2014 elections are unlikely to alter the terrain in very many states.