Obamacare

01.08.14

States Edge Closer to Medicaid Expansion: Who’ll Go First?

Several GOP governors turned down federal money to expand their states’ insurance for the poor. Now even some hard-core conservatives are about to take the cash.

When will some states that initially refused federal money to expand Medicaid for their poor citizens pull a flip-flop and accept it? Because it’s inevitable that some will—and as they do, the Republicans’ sabotage of Obamacare will be profoundly undermined, and people’s concomitant opposition to the law will start to vaporize.

This thought is occasioned by the publication yesterday by Theda Skocpol, the esteemed Harvard sociologist and political scientist and head of the excellent Scholars’ Strategy Network, of an eye-popping chart about how health-care coverage is proceeding so far in various states. Skocpol divides the 50 states into five categories: “full-go,” the 14 states that have accepted the Medicaid expansion and set up their own exchanges; “supporters,” the seven states expanding Medicaid and working within the federal exchange; “exchange partners,” the two states working with the federal exchange but not expanding Medicaid; “Medicaid only,” the four states expanding Medicaid but defaulting on the exchanges; and “just say no,” the 23 states that aren’t accepting Medicaid money or working with the exchanges

140108-tomasky-chart
Scholars Strategy Network

In each of these five categories, what percentages of previously uninsured are gaining coverage? It’s about what you’d think, but it’s pretty astounding to see.

In the full-go states, the average Medicaid enrollment (along with S-CHIP, which is for children) is 42.9 percent of those eligible, and the average attainment of coverage through exchanges is 37.2 percent. In the supporter states, those numbers are 15.7 and 5.8 percent, respectively. And in the “just say no” states, they’re feeble—just 1.5 and 5.6 percent.

In other words, says the SSN website, “It is apparent that Affordable Care is doing best in the states that are really trying to carry it through.” In sum, the site continues: “America’s new health reform can work, but it depends greatly on the capacities of the various states to administer challenging reforms—and even more on the willingness of state-level officials to pitch in to shape reform to local needs, as the original legislation intended.”

Now. This raises an obvious question. As the months pass, I can’t help but think, the people in the “just say no” states are going to see that people in other states are getting health insurance—in many cases, federally subsidized health insurance. This will certainly be true in the “no” states that border “yes” states, where people often watch the same local newscasts and know people who live on the other side of the border. And there will be—indeed, there has already been—pressure to take the Medicaid money applied to Republican governors of blue states, where Democrats control the legislature and/or where Obamacare isn’t that unpopular.

Republican governors have been trying to make sure that coverage-enrollment rates stay low and the law looks like a failure. But that position can’t hold forever.

So how long will it be before some of these governors flip and decide they’re going to take the Medicaid money?

Here’s a map of the states,  color-coded to show Medicaid expansion. The first one that’s going to flip this year is Virginia, where the still-pre-indicted ex-Governor Bob McDonnell wouldn’t have anything to do with Obamacare, but where the new governor, Terry McAuliffe, is ready to play ball. Virginia will be the second breach of the Old Confederacy wall (Arkansas has accepted what it calls a “customized” Medicaid expansion, in which it takes the money but places conditions on doling it out that aren’t in the federal law). Missouri is another state with a Democratic governor—Jay Nixon. His legislature is opposed, but he’s pushing, with arguments aimed specifically at the business community.

Let’s move on to the much more interesting category—states with Republican governors. Who’s thinking about playing Obamacare ball? Some pretty hard-shell conservatives: Rick Snyder of Michigan, Tom Corbett of Pennsylvania, Terry Branstad of Iowa; weirdly, Mike Pence of Indiana, and maybe-just-maybe even Rick Scott of Florida. 

An official at the Department of Health and Human Services tells me that an agreement is expected to be reached in April with Michigan, where the terms of acceptance of the money are being finalized. Pennsylvania officials have been conducting a “listening tour” (this is one unfortunate Hillary Clinton legacy!) among the citizenry and is slated to submit a plan to HHS by the end of this month. The agreement with Iowa, which will be “customized” along Arkansas lines, is pretty much finalized. With Indiana, there’s more work to be done, but talks have been ongoing. 

Surprisingly, the official tells us, Utah is inching toward accepting the money, as is Tennessee. These are deep-red states, but in both, there’s a respectable grassroots movement agitating for buy-in. The remaining blue states that have GOP governors and haven’t bought in are Wisconsin and Maine. Wisconsin is probably a no-go—Gov. Scott Walker’s presidential ambitions will likely prevent any progress there. Maine’s governor, Paul LePage, is a caveman,  so Maine is a mighty river to cross. However, the state legislature has twice passed laws to have the state take part in the expansion, and it’s expected to do so again very soon. LePage can keep vetoing, but in a state that blue, not forever.

The big prize is Florida, where Rick Scott is running for reelection against Charlie Crist, the ex-Republican turned Democrat. Usually, you’d think an election means a Republican, especially a right-winger like Scott, would spend the year kicking Obamacare in the teeth. And he may yet. But Scott made the unforced “error” of endorsing the Medicaid expansion for about 20 minutes last year. Crist was quick to point out that the money could finance health coverage for 1 million people in the state. That is not, as it turns out, crazy unpopular. In recent polling, Crist is ahead, one would almost say comfortably ahead, of Scott. So in Florida, backing Medicaid expansion may become the politically expedient thing for the Republican.

Virginia’s a big state. Michigan, Missouri, and Pennsylvania are big states. Iowa and Indiana are decent-size states. If all of them take the Medicaid money this year, that would be huge for Obamacare. Eyes would then turn to Georgia, and even Texas.

As Skocpol’s report makes plain, and as we’ve known anyway, Republican governors, no doubt getting nudged in the ribs by national Republicans and conservatives, have been trying to kill Obamacare by not participating in it, making sure that coverage-enrollment rates stay low and the law looks like a failure. But that position can’t hold forever. There’s too much money in play here for governors to say no. And when four or so more big states have fallen in line, the national numbers start to look pretty darn good. And people will start to have health insurance. What a crazy thought.