Voters Consider Medicaid Expansion In Holdout States

From Georgia to Wisconsin, Florida to Maine, this election cycle will have major implications for Medicaid in non-expansion states.

Georgia Democratic gubernatorial candidate Stacey Abrams speaks as Republican opponent Brian Kemp looks on during a debate Oct. 23 in Atlanta.
AP Photo/John Bazemore, Pool
Nov. 4, 2018, 8 p.m.

For Democratic gubernatorial candidate Stacey Abrams, Medicaid expansion is not just about increasing the number of people with health care, it’s also about saving Georgia’s rural communities.

“Rural Georgia has been losing hospitals at an alarming rate,” said Abrams during an Oct. 23 debate. “Because of that loss, we have companies leaving, we have people without access to health care, and we aren’t doing the kind of economic-development work we can do.”

Recent data from the North Carolina Rural Health Research Program shows that seven rural hospitals have closed in Georgia since 2010. “With the expansion of Medicaid, we can save rural hospitals, cover more than half a million Georgians, and invest in all of those communities,” said Abrams.

Her health plan even got a shout-out from Oprah Winfrey, who spoke at a campaign rally Thursday. “I’m here today because Stacey Abrams cares about the things that matter,” said Winfrey. “She cares about Medicaid expansion.”

But her Republican opponent, Secretary of State Brian Kemp, disagrees. “Expanding a broken government program is no answer to solving the problem,” he said during the October debate.

Georgia is one of 17 states that did not expand Medicaid under the Affordable Care Act. And Georgia is one of a handful of states where Election Day may determine the future of the program.

While experts said that Medicaid reform and expansion repeal is not off the table in the future, particularly if the House does not flip to a Democratic majority, it may be a difficult task to roll back a program that provided benefits to more people.

Even in this election cycle, Ohio gubernatorial Republican candidate Mike DeWine and Michigan GOP candidate Bill Schuette “softened” on their opposition to Medicaid expansion, said the Kaiser Family Foundation in a brief.

The expansion under Obamacare provided increased health care coverage and access to benefits, as well as an inflow of federal dollars to states, said Robin Rudowitz, associate director for the Program on Medicaid and the Uninsured at Kaiser. “There’s fiscal effects for states as well as for providers, because providers, hospitals, clinics have seen reductions in their uncompensated care,” she said.

Six non-expansion states are home to gubernatorial races that are considered toss-ups, including Georgia, according to an analysis by Avalere Health. The others are Florida, Kansas, Maine, South Dakota, and Wisconsin. Three more states—Idaho, Nebraska, and Utah—have ballot initiatives that would expand their programs.

Avalere estimates that around 2.7 million more people could end up eligible for Medicaid coverage between the nine states.

Even if Abrams does not win the governorship, Georgia may still be forced to consider expansion, said Daniel Franklin, a political-science associate professor at Georgia State University.

“If Kemp wins, they may think about expanding Medicaid in such a way, they may call it Kempcare or something like that, so it’s not as if he is buying into Obamacare,” said Franklin. “But that may be the only and the cheapest way of saving rural hospitals because rural health care in Georgia is going away.”

The issue of Medicaid expansion has also been raised in the scorched-earth Florida race, with Democratic candidate and Tallahassee Mayor Andrew Gillum pressing for expansion of while Republican candidate Ron DeSantis maintains his opposition.

“If we expand Medicaid here in the state of Florida, we will extend access to health care for over 800,000 of the most medically needy Floridians, 800,000,” said Gillum during a late October debate. “By doing so, we will pull down $6 billion from the federal government that right now is being given away to other states because we philosophically disagree with getting folks access to health care.”

DeSantis’s campaign sent out a statement explaining the congressman’s opposition the following day, writing that when the federal match rate drops to 90 percent in 2020, “Floridians—not the federal government—would be paying $564 million per year in additional taxes by 2022.”

Republicans are focusing their attacks on Gillum for his “socialist” ideas, said Republican strategist Mac Stipanovich. “[Gillum] believes that health care is a universal right and supports Medicare-for-all... but recognizes, and this is almost a parenthetical, that that’s beyond the reach of Florida’s governor, so he would support Medicaid expansion,” said Stipanovich.

During the Oct. 21 debate, DeSantis attacked Gillum for his support for Sen. Bernie Sanders’ Medicare-for-all plan, while Gillum tried to refocus to Medicaid expansion and knocked DeSantis on protections for people with preexisting conditions.

Overall, a majority of voters in non-expansion states would like to see expansion of the program, according to a Kaiser Family Foundation poll. In Florida, about half of voters said they are more likely to vote for a candidate who wants to expand Medicaid and Gillum has an advantage over DeSantis as most Floridian voters trust him to do a better job on health care issues.

Rudowitz noted that the Trump administration has provided conservative states tools to implement changes to Medicaid, such as adding work requirements that might restrict enrollment. The future of Medicaid in Wisconsin was in the spotlight this week when the Centers for Medicare and Medicaid Services approved a waiver allowing the state to impose work requirements and charge certain beneficiaries premiums.

But the timing of the waiver’s approval may not have been helpful for incumbent Gov. Scott Walker, who is in a tight race with Democratic challenger Tony Evers.

“Republicans have been bending over backwards to reassure voters who are concerned about their health care after the election,” said Barry Burden, director of the Elections Research Center at the University of Wisconsin-Madison. “So the timing of this waiver approval, even though it’s something that Walker supports, the timing of it just was not great because it did help feed the Democratic message that Walker is uncaring about people with difficult health care situations.”

Soon after CMS approved the waiver, the Associated Press reported that Walker wants to keep the exact language from the Affordable Care Act protecting pre-existing conditions. “No matter what happens in the courts or in the Congress, in Wisconsin we’ll codify that, the exact same language that’s in the Affordable Care Act. We’ll make sure everyone living with a pre-existing condition is covered here in the state,” Walker said Thursday, according to the AP.

Evers has attacked Walker for not taking advantage of the Obamacare Medicaid expansion in the past.

“[Walker] has hurt the people of Wisconsin,” said Evers in an Oct. 19 debate. “Not only did he oppose Obamacare, but as a result of that opposition, he did not take the Medicaid-expansion money that the Wisconsin citizens deserve. So he left hundreds of millions of dollars on the table… I’m going to take that Medicaid money and we’re going to plow it into the system and make health care more affordable to all.”

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