In Omaha last week, a volunteer asks people if they would like to sign a petition to expand Medicaid in Nebraska. States including Idaho, Utah, Nebraska, and North Carolina are weighing expanding their programs.
The push to expand Medicaid is gaining traction in some Republican states that previously rejected the idea, thanks to grass-roots efforts to let voters weigh in directly on the issue and recent changes in the program that make it more friendly to conservatives.
States including Idaho, Utah, Nebraska, and North Carolina are weighing expanding their programs, and the debate is also playing a central role in the midterm contests in Florida, Georgia, and Kansas. All were won by President Donald Trump in the 2016 election.
Traditional Medicaid typically covers such groups as low-income families who qualify for Social Security and pregnant women and children meeting income requirements. Medicaid expansion, part of the Affordable Care Act, enables states to cover more low-income adults up to age 65.
Some Republicans are finding expansion more palatable now that the Trump administration is letting states impose work requirements on recipients. At the same time, grass-roots groups have succeeded in getting expansion on the ballot in the form of ballot initiatives, taking advantage of a political climate that has shifted since Republicans in Congress failed to repeal the ACA.
Last week, Democratic Gov. Ralph Northam of Virginia signed a budget expanding Medicaid to up to 400,000 residents. The plan’s requirement that many nondisabled recipients work or volunteer was key to getting the support of Republican state lawmakers who had previously opposed expansion in the centrist state.
“The ability to embrace a work requirement is a big part of it,” said Matt Salo, executive director of the National Association of Medicaid Directors. “If you’ve spent eight years running against the concept of Obamacare with all your heart and soul, the ability to pivot to embrace its biggest element is still difficult.”
That is one reason the push to expand Medicaid has come to a standstill in Maine. Voters approved an expansion in a ballot referendum last year. But GOP Gov. Paul LePage, who opposes it amid concerns about the cost, refused to launch the process. A judge ordered the state to do so and last week the LePage administration appealed, leaving coverage for about 70,000 people in legal limbo.
To date, 34 states and the District of Columbia have expanded Medicaid within their borders.
Medicaid expansion has fueled the biggest coverage gains under the Affordable Care Act, also called Obamacare. Enrollment in states that expanded the program increased by 13.8 million between 2013 and 2017, according to the Medicaid and CHIP Payment and Access Commission, or MACPAC.
The recent uptick in interest in GOP states reflects a fundamental political shift, analysts from those states say: Supporting expansion is becoming less of a political risk.
In the aftermath of the failed GOP repeal effort, the future of the expansion program, which is embedded in the ACA, appears more certain. At the same time, Republicans are finding they can shape expansion to conservative ideals including work requirements, premiums, and health-savings accounts.
Republican Kentucky Gov. Matt Bevin agreed to keep Medicaid expansion for more than 400,000 residents of his state—as long as the courts allow work requirements. Opening arguments in a lawsuit challenging those requirements will be heard June 15 in U.S. District Court in Washington, D.C.
In some states, voters have signaled they want Medicaid to grow even if lawmakers don’t. Voters will decide on Medicaid expansion referendums in Idaho and Utah, and supporters expect to place expansion on the ballot in Nebraska’s general election. Advocates also hope to pass a ballot initiative that would renew expansion in Montana, where the program expires in 2019.
The midterms will shape Medicaid policies, either in expanding coverage or, in some cases, rolling it back.
In Georgia, Stacey Abrams, the Democratic nominee for governor, is campaigning on Medicaid expansion. Mike DeWine, the Ohio attorney general who is running for governor, has said he doesn’t believe the state’s Medicaid expansion is sustainable.
Many Republicans remain opposed to expansion, and the Trump administration argues that it benefits working-age adults at the expense of the very poor women and disabled.
But some health analysts said the action shows that the ACA has persuaded more people that the federal government has a larger role to play in providing health coverage.
“Even in non-expansion states people are in favor of Medicaid,” said Diane Rowland, executive vice president at the Kaiser Family Foundation.