How the Midterms Factor Into Medicaid Expansion

This was published as a Wall Street Journal Think Tank column on November 3,  2014.


A lot of attention has been paid to what a shift in control of the Senate in the midterms might mean for the Affordable Care Act and other big policy issues. As ACA implementation has shifted to the states, governor’s races may be just as important, particularly when it comes to whether states expand Medicaid.

Six of the 23 states that have not expanded Medicaid have toss-up governor’s races: Alaska, where Republican incumbent Sean Parnell is running against independent Bill Walker; Florida, the most closely watched race, where former governor Charlie Christ, now running as a Democrat, is trying to unseat Republican Gov. Rick Scott; Georgia, where incumbent Republican Nathan Deal is trying to hold off Democratic state legislator Jason Carter; Kansas, where state legislator Paul Davis is challenging Gov. Sam Brownback; and Wisconsin, where Gov. Scott Walker is being challenged by Mary Burke; and Maine, where Democratic state legislator Mike Michaud and independent Eliot Cutler are running against Gov. Paul LePage.

In the states that do not expand their Medicaid programs, uninsured people with incomes below the poverty level end up in a “coverage gap” where they have no options. They make too much money to qualify for their state’s Medicaid program or don’t fall into their state’s eligibility groups, or they don’t earn enough to qualify for  insurance tax credits under the ACA. In Alaska, 12,000 uninsured people fall into this gap; they would be eligible for coverage if the state expanded Medicaid. In Georgia, there are 409,000. In Florida, 764,000. Kansas has 78,000 and Maine 24,000. (Wisconsin has none since its gap population was already covered through a prior initiative.) This infographic shows the size of the gap group in every state.

But it’s not that simple, of course. In every state where a Democrat wins the governorship, they will either need to deal with the state legislature or, where state law allows, maneuver around the legislature using executive authority. Of the six states noted above, three–Alaska, Florida, and Georgia–have safely Republican legislatures. The Kansas House is up for election, but the state Senate is not. Wisconsin’s legislature leans Republican. Only the Maine legislature leans Democratic. The strength of powerful individual legislators who oppose expansion can matter as well. In fact, in Florida Gov. Scott advocated Medicaid expansion but could not persuade the legislature to go along.

It is likely that any Democratic governor who wins election would push for Medicaid expansion. Greater coverage for low-income residents will no doubt be a priority for them, and they will want the substantial federal funding their state receives when the program expands. They do not share the views about the president, the Affordable Care Act, and Medicaid held by conservative red-state governors and legislators who have resisted expansion. But as a former state human services commissioner working for Tom Kean, a moderate Republican governor in New Jersey who tried to work with all sides, I understand well that if they win it will be up to these governors to knit together a coalition in support of expansion and to work with their legislators if Medicaid expansion is to move forward in their states.

One big thing governors interested in expanding Medicaid may have going for them is that the ACA has cooled as a political issue and is likely to cool further after the midterms and after 2016, with a change in the White House. As it does, conservative opposition in their states could gradually diminish. In states where Democratic governors win this week, and in all of the states that have not expanded, the process of embracing a Medicaid expansion is more likely to be gradual than quick.

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