The midterm elections could bring sweeping changes to Medicaid, from possible eligibility expansions to new rules requiring low-income people to work, depending on voters’ choices for governors’ offices and state legislatures across the country.
Medicaid covers more people than any other federally funded health program.
Medicaid expansion advocates are optimistic that voters in Idaho, Nebraska and Utah will pass ballot initiatives to broaden coverage, buoyed by strong polling numbers and the fact that petitions in those states to force ballot votes garnered tens of thousands of more signatures than needed. Experts say other states, such as Kansas and Georgia, could expand eligibility, depending on the electoral outcomes, especially if conservative priorities such as work requirements are added.
Uncertainty around the future of Medicaid expansion emerged in recent years because of court challenges and Republican efforts to repeal the 2010 health care law, but states that put their expansion discussions on hold are now revisiting their thinking, said Ben Sommers, associate professor of health policy and economics at Harvard University.
“States are going to be back in this game, and we may see the steady trickle (of expansions) resume,” Sommers said.
If approved by voters, expansions in Idaho, Nebraska, and Utah would extend health insurance to more than 300,000 low-income people. Meanwhile, in Montana, another ballot initiative, if approved, would renew the state’s existing expansion, which covers nearly 100,000 people though it expires next year.
It’s possible that Florida and Missouri could hold expansion ballot initiatives in 2020, said Kelly Hall, director of health policy and partnerships at The Fairness Project, a group promoting ballot initiatives.
Watch: All You Ever Wanted to Know About Health Care Ahead of the 2018 Midterms
But experts note that a vote for expansion by ballot initiative doesn’t necessarily mean an easy path forward if state officials balk. Take the case of Maine, where Republican Gov. Paul R. LePage refused to implement expansion after nearly 60 percent of voters passed an expansion ballot initiative in 2017. The state Supreme Court ordered him this summer to move forward, but even now, the state is slow-walking the process with implementation likely to wait until next year at the earliest when LePage’s term ends.
Gubernatorial candidates competing to replace LePage are in favor of Medicaid expansion — Democrat Janet Mills and independents Terry Hayes and Alan Caron all support expansion. Republican Shawn Moody, while initially indicating that he would follow LePage’s lead in opposing it, recently said he will follow the law and expand as long as funding is available.
Earlier this week, the Centers for Medicare and Medicaid Services appointed former Maine health commissioner and staunch Medicaid expansion opponent Mary Mayhew as deputy administrator and director of Medicaid and the Children’s Health Insurance Program, the top federal official overseeing the program. The agency said Mayhew will recuse herself from decisions related to Maine.
Experts say it would be politically dicey if governors in any states that pass expansion this year ignore their constituents’ will.
In Nebraska, advocates are confident a Maine-like situation won’t arise if voters approve expansion.
“The ballot language that voters will be deciding on was carefully crafted to avoid the exact issue that Mainers have run into with Gov. LePage,” said Meg Mandy, campaign manager for expansion advocacy group Insure the Good Life.
Republican Gov. Pete Ricketts, who is up for re-election in the Cornhusker State, opposes expansion but said he will let voters decide. But a former state lawmaker and current state senator who unsuccessfully sued to prevent the question from being on the ballot suggested further legal action could be taken if voters approve it.
The November elections could also affect expansion in other red states.
Kansas state lawmakers passed expansion legislation last year only to have it vetoed by then-Gov. Sam Brownback, a Republican. His successor, Jeff Colyer, also opposed the idea. But a close race for the governor’s seat this year could upend that.
Democratic candidate Laura Kelly and independent Greg Orman both favor expansion, while Republican Kris Kobach is opposed.
Health care experts are also monitoring Georgia and Florida, where expansion is a hot topic.
Democrats might not need a legislative majority to move on expansion in some states, said David Jones, an assistant professor at Boston University’s School of Public Health. They just need enough seats to pressure moderates who could help them cobble together a coalition, he said.
That occurred earlier this year, when Virginia lawmakers voted to extend Medicaid coverage to roughly 400,000 low-income adults, following a 2017 electoral upset that gave Democrats 15 more seats in the House of Delegates. The shift left Republicans with razor-thin margins in both chambers.
After that, moderates were more willing to accept expansion, Democratic Gov. Ralph S. Northam said Thursday at a national conference in Washington. The lingering effects of the recession, struggling rural hospitals’ calls for expansion and the opioid crisis also fueled support for broadening Medicaid, Northam said.
Experts say similar changes in state legislatures could ultimately propel holdout states closer to expansion. Seventeen states have not adopted expansion, according to the Kaiser Family Foundation.
“Florida in some ways is the holy grail of Medicaid expansion,” said Jones of Boston University. “If that were to flip, I think it would be a huge moment for Medicaid.”
The chances of that are remote, however, even if a Democrat becomes governor, because Republicans still have the upper hand in the state legislature. Democrats are unlikely to take the Florida House but might pick up Senate seats, Jones said.
Incoming Florida Senate President Bill Galvano told the Miami Herald last month that he does “not believe there is support in the legislature for the expansion of Medicaid contemplated in the Affordable Care Act.”
Georgia is another red state where the forecast is iffy.
Expansion became a focus of the state’s gubernatorial race with Democrat Stacey Abrams, a former leader in the legislature, ardently supportive and Republican Secretary of State Brian Kemp staunchly opposed.
Even with an Abrams win, expansion advocates would face an uphill battle in the GOP-controlled legislature. However, some conservatives — particularly those from rural regions where hospitals are struggling — expressed tentative support in the past.
Georgia is analogous to Virginia in the level of voter support for expansion, said Patricia Boozang, a health care expert with consulting firm Manatt, Phelps & Phillips. The rural health issue is a big factor.
Boozang added that if some red states do expand, they may add conservative-friendly elements, such as work requirements, like Virginia did.
The November elections could also spur changes in how states run their existing programs.
A Democratic gubernatorial win in a state such as Michigan might lead the state to reconsider its proposal to add work requirements to Medicaid, Boozang said.
But in more conservative states, elected Republicans could push for more work requirements and other changes, Jones said. Kentucky is one example of how new leadership led to rollbacks, he said.
Republican Gov. Matt Bevin asked federal officials to operate Kentucky’s state-run insurance exchange and threatened to end Medicaid expansion. While he ultimately didn’t eliminate expansion, Bevin did pursue significant changes, including work requirements.
Governors and legislators in states seeking work requirements, such as Arizona, Michigan and Ohio, play important roles in shaping those rules, Jones said. While work rules share similarities, they vary on key issues such as the number of hours people must work or whether individuals who fail to meet the requirements are locked out of coverage.
Full-on repeals of expansion are politically unpalatable since Medicaid is popular among voters, Sommers said. But a newly elected Republican governor could push for work requirements, which are also popular even among some Democrats, he said.
“It has much less public outcry,” he said. “It’s a much less contentious stand to take.”