From the moment that the Supreme Court allowed states to opt out of the Affordable Care Act’s expansion of Medicaid – in a 7-2 ruling joined by Justices Breyer and Kagan – I’ve been among the more pessimistic when it comes to assessing the willingness of states to accept the expansion. Yes, the deal being offered states seems too good to pass up – the federal government covers the full cost of the expansion for the first three years, sliding down to 90 percent for the long term. But the green eyeshade numbers wouldn’t be enough in many states to overcome the deep animosity toward anything associated with Obamacare and the general reluctance to expand the safety net for the poor.
My pessimism has been validated. Roughly half of the states are still refusing to accept the expansion, leaving uncovered the more than 5 million people who were supposed to qualify under the law – anyone making up to 138 percent of the poverty level.
That said, there have been a few indicators recently that have left me wondering whether a tide might be turning on this, including one I already noted earlier this month, the election of Terry McAuliffe, who made Medicaid expansion a central issue in his race for Virginia governor. In no particular order, here are six other recent developments:
1. Mike Pence has requested a meeting with Health and Human Services Secretary Kathleen Sebelius to discuss ways that Indiana could participate in the expansion short of fully accepting it as called for by the law. It’s too soon to know whether this is a sincere attempt to expand coverage, akin to the compromise Mike Beebe, the Democratic governor of Arkansas, worked out for his state, or just a cynical ploy to offer an alternative that Pence knows that the feds would deem inadequate. Still, though, it’s striking that Pence, a staunchly conservative former congressman leading a state that went for Mitt Romney by 10 percentage points after barely tipping blue in 2008, would see it in his interest to even be seen discussing Medicaid with the dread bogeyman of Obamacare, Sebelius.
2. John Kasich seems to have boosted his standing with Ohio voters with his controversial decision to force through Medicaid expansion there without the support of his fellow Republicans in the legislature. A new poll shows 51 percent of respondents favoring Kasich’s move and 40 opposed, with Kasich leading his likely Democratic challenger by seven points. Yes, he also has Republican strategists giving blind quotes about how his move crossed him off the list for the 2016 presidential ticket. But he has clearly concluded that Medicaid expansion is in his interest with the general election electorate in the ultimate swing state, and polls suggest he may be right.
3. Tennessee Governor Bill Haslam, a Republican, is inching toward accepting expansion, possibly via an Arkansas-like compromise. He says that he’ll have to bring any expansion to the GOP-controlled legislature for approval, a tough bar to pass, but he sure sounds like someone who wants to find a way to make expansion work. I have a particular journalistic interest in this decision – last year, I spent a weekend in the hills of southern Tennessee with dozens of uninsured working poor, nearly all of whom would be covered by the Medicaid expansion, and nearly all of whom had no idea that the law would provide them with coverage. But that was just before the Supreme Court ruling that threw everything into uncertainty, and all of those people are still waiting for coverage, as if the law had never passed in the first place – as if, really, their lack of interest in it was perfectly appropriate, given that it is providing them with zero benefit.
4. The way Republicans are talking about the Medicaid issue is softening slightly. Reports from the Republican Governors Association confab in Arizona last weekend were all about the divisions between the governors who had backed the expansion and those who hadn’t. But what struck me was how relatively mild the language used by the expansion-rejecting governors was. Mississippi Governor Haley Barbour, whose state has rejected the expansion, said he didn’t think Republicans who had accepted it would necessarily be punished for that by GOP primary voters: “Some people may try to make it an issue, but I think they’re going to find out it’s not the kind of issue they expect it to be,” he said. Louisiana Governor Bobby Jindal, another expansion-rejector, said, “I do think everybody should have health insurance. I just think ACA and Medicaid expansion were the wrong way to solve that problem.” But, “Every governor has to make the best decision for their state, so I’ve never second-guessed or criticized or questioned those governors who made a different decision than I did. Let’s stop thinking about 2016.”
Now, this tone was surely due partly to simple collegial cordiality. But still, some expansion-rejecting governors seemed less willing to bash the Medicaid part of the law than the other half of it, the insurance exchanges where people further up the income ladder are supposed to get coverage, which have been so confounded by technical troubles. There’s irony in this, of course, given that the exchanges are based on the conservative-preferred model of private-sector insurance plans competing for consumers. But it’s not inconceivable that there are other Republicans who, like Kasich and New Jersey Governor Chris Christie, will find it easier to support expanding coverage for the state’s neediest even as they continue to rail against the law’s mechanism for guaranteeing coverage to those of greater means. That’s just what happened in the recent special election for an open congressional seat in northeastern Louisiana, where Republican Vance McAllister said he opposed “Obamacare” but backed the Medicaid expansion – and won.
5. The realities of the financial fallout of the decision are becoming clearer. Governors and legislators rejecting the expansion have been warned over and over that they are leaving hundreds of millions in federal dollars on the table. But now other numbers are coming to bear as well – states are rejecting expansion are actually being twice, because they are not only leaving that money on the table but also bracing for big cuts in federal funding for hospitals that see an unusually high share of uninsured patients. The law calls for cuts in that funding since the whole idea was that fewer patients would now be uninsured. Already, at least five hospitals have closed in states where Medicaid wasn’t expanded. This gives even more ammunition to the health care industry lobbyists in states urging lawmakers to come around on expansion. Meanwhile, it's becoming more evident just how much expansion-accepting states are benefiting at the expense of taxpayers in expansion-rejecting ones, a fact that politicians in the the latter states, including some Republicans, are sure to latch onto sooner or later.
6. As the expansion proceeds in the states that are participating, the moral element of the decision is going to become harder and harder to ignore. It’s one thing to talk about the millions of people left uninsured in the rejecting states in the abstract. But it’s another thing to start seeing in the states that are accepting the expansion the reactions of those benefiting, as was described so well by Stephanie McCrummen in a recent Washington Post dispatch from Kentucky, the only Southern state accepting the expansion outright. One man excitedly tells the outreach worker what he’ll be able to do now that he’s covered: “I got some warts on me I got to take off, some moles. I might have that colonoscopy done. My mom had colon cancer twice. I never had money to do it.” Another man: “Now, I have problems with my teeth. I need to get all of them pulled.” “It does cover that,” the outreach worker tells him. “Oh, that’s great!” he says.
As more of these accounts surface, and as word of mouth spreads across borders of what the law is making possible for those in the expansion-accepting states, it’s going to become trickier for governors and legislators to hold the line. “I always try to put myself in the shoes of somebody else to say: ‘How would I feel if I didn’t have health insurance? Are you kidding me?’ It’s going to save lives. It’s going to help people, and you tell me what’s more important than that.” Who said that? John Kasich, Republican of Ohio.