Conservative states that refused to take up Obamacare’s offer to expand Medicaid are inching towards this option now that congressional Republicans are backing away from repeal and the Trump administration has given states more flexibility over their programs.
Medicaid expansion was consistently on the chopping block last year as Republicans in both chambers of Congress attempted to wind down the program and impose even deeper long-term cuts. But many Republicans on Capitol Hill are stepping away from their full-repeal goals.
Now, some GOP state lawmakers and governors appear to be softening on the idea.
“This administration has been willing to look at waivers that the past administration’s not,” said Republican Utah Gov. Gary Herbert. “So even under the Affordable Care Act, under the current law of the land, I think there [are] ways to massage and have Utah participate with the Medicaid program, which will be enhanced, and we’re looking at that right now.”
The Trump administration in January showed its willingness to work with states that want to implement work requirements as part of their Medicaid program and has approved such proposals for Kentucky and Indiana. The increased flexibility may actually push some red states to take up expansion options provided by the Affordable Care Act.
“I think if the Obama administration had embraced some of those concepts early on, and said ‘Hey, yeah, you want to do a partial expansion, you want to do a work requirement,’ I think you’d have a lot more states who would’ve done the expansion by now, a lot more,” said Matt Salo, executive director of the National Association of Medicaid Directors.
Republicans in both the Virginia and Utah legislatures are showing openness to expansion, and there’s increasing momentum in both states behind the idea. If the plans are successful, this marks a shift in attitudes toward expansion in states that had steadfastly refused to change their programs under the Obama administration.
The Utah legislature is considering a proposal to expand its program with features that were not welcome under the previous White House. State Republican Rep. Robert Spendlove introduced a bill this week that would expand the program to people whose incomes are below 95 percent of the federal poverty level and would apply work requirements to certain adults.
Spendlove told National Journal that he had a similar proposal two years ago that the Obama administration said it would not approve because the expansion idea did not fit with the White House’s overall policy objectives.
“I was talking to an Obama administration official and I said ‘Is this something you are willing to consider?’” said Spendlove, “and their response was, ‘Don’t even try, there’s no way we’ll approve this.’”
Spendlove added that, if the plan is approved, Utah could show a path forward for other states. “This could be a model for other states to use as well, especially those states that have not expanded Medicaid at this point,” he said. “Because from what I’ve heard, many states similar to Utah are really concerned about their ability to tailor a program to their needs.”
Virginia has also shown recent energy around extending Medicaid coverage to a large population of the state. Last week, the Virginia House of Delegates passed its version of the state budget that included a Medicaid expansion proposal with work requirements for able-bodied adults. But the Senate passed its own bill that did not include such a proposal. Democratic Gov. Ralph Northam told Politico on Friday that he and state lawmakers are very close to an agreement to expand Medicaid.
Democratic North Carolina Gov. Roy Cooper hopes that his state would follow suit. “We have been pushing for Medicaid expansion in North Carolina even before I became governor,” he said. “It’s important for us to be able to draw down those billions of dollars. We could potentially insure over 600,000 North Carolinians, create tens of thousands of health care jobs.”
In November, the state’s health department submitted a Medicaid waiver with changes to the program, including work requirements. But the enforcement of these requirements is contingent on the passage of a bill that would expand Medicaid.
Cooper, however, expressed concerns about potentially making certain beneficiaries work. “You know the Republican leadership in the General Assembly I think would only expand if there were some type of work requirement,” he said. “I think it causes a lot of unnecessary paperwork and most of these people that we would expand to already are working, but I’m open to all options with the Republican leadership in the General Assembly to try to get it done.”
But the increased flexibility over how the program is tailored may not be enough to get over the political and fiscal barriers that other non-expansion states face.
“The optics of embracing something as vilified as this particular law would just guarantee that anyone who did it would be primaried from the right,” said Salo, who noted that there are politicians that spent the better part of a decade running against the Affordable Care Act.
Republican Wyoming Gov. Matt Mead said he did not think his state at this point would try to grow the reach of the program, adding that he had made two attempts to do so.
“For us in Wyoming, as the federal match as it was set up to decrease every year, my belief is if we couldn’t get it through with the higher match the likelihood of getting it through now is even less,” he said. “Combine the fact that with the tax-cut package and with uncertainty even where the ACA ultimately ends up, I think that the likelihood that the state of Wyoming expands Medicaid is pretty small and not practically going to happen.”