By FOCUS, a Leonine Business
To date, 32 states and the District of Columbia have expanded their Medicaid programs as authorized under the Affordable Care Act. The remaining 18 which have not – mostly red states – are finding it increasingly difficult politically to continue to hold off on expanding the program. This delay however, comes with a cost; in the years since the expansion began, states have been required to pick up an increasing percentage of the total cost. The federal government covered 100 percent of the costs through 2016, which decreased to 95 percent in 2017 and 94 percent in 2018. This number will continue to decrease to 93 percent in 2019, before bottoming out at 90 percent in 2020 and beyond.
In spite of the growing costs, the expansion has proven popular around the nation and has had a positive economic impact on the states that have agreed to it. A study by the Robert Wood Johnson Foundation found that states that expanded saw spending reductions through reduced spending on healthcare for the uninsured, as well as increased revenue through the economic activity generated by the expansion. Montana, which expanded its program in 2016, has seen such strong economic growth from the expansion, according to Montana Public Radio, that the program is now effectively paying for itself, despite the rising costs at the state-level.
With pressure mounting both economically and politically – a majority of both political parties now have a favorable view of Medicaid, according to the Kaiser Family Foundation – lawmakers that were once reluctant to expand are now warming up to the idea, lest voters have their say in the upcoming state legislative elections.
Arkansas, which expanded Medicaid but was considering letting funding for the expansion lapse, officially signed off on a continuation of its program this week after months of looming uncertainty as to whether lawmakers would continue to fund the program or let it expire without additional funding. According to the Arkansas Democrat-Gazette, the Republican controlled legislature quietly passed SB 30 on March 7; the bill was then quickly signed into law by Republican Gov. Asa Hutchinson on March 9.
The state also recently received approval from the federal government to implement work requirements on certain enrollees beginning in June, which may have been pivotal in persuading lawmakers to approve a continuance of the program. Work requirements such as this have been an effective means of sweetening the pot for reluctant lawmakers, who have historically been wary of any expansion of government spending programs. They have shown to be a facilitator of compromise in a number of states, including the conservative stronghold of Indiana, which was the first state to implement such a requirement alongside the Medicaid expansion, under then-Governor Mike Pence.
Virginia, which has been in a power struggle between the Republican controlled General Assembly and Democratic governor’s office over the issue for years, has once again left the question unresolved. Earlier in the year, it appeared that a compromise may be found, with Democrats nearly taking control of the lower chamber in 2017’s legislative elections, and newly elected Democratic Gov. Ralph Northam making concessions on work requirements. However, the legislature adjourned on March 10 without passing a budget – the legislative vehicle for the expansion – leaving the question in limbo. Governor Northam is expected to call a special session in the coming weeks to resolve the budget and the question of expansion.
In Kansas, advocates are looking to take another crack at passing the expansion this year, after lawmakers narrowly fell short of overriding Republican Gov. Sam Brownback’s veto of an expansion bill in 2017. A bill has passed the Senate, according to the Lawrence Journal-World, though it still remains unclear if lawmakers can muster the votes to override a veto, with the partisan composition of the legislature remaining the same as in 2017.
Utah legislators also managed to pass an expansion bill that includes work requirements this year, according to The Kansas City Star, but the state is also facing the prospect of a referendum in November which could further expand the program, and eliminate the work requirement.
Advocates have been increasingly looking to the referendum process as a means to force the issue after the success of Maine doing so in 2017, where Republican Gov. Paul LePage vetoed the issue five consecutive years. According to Forbes, supporters in Idaho, Missouri and Nebraska are seeking to see the question put to voters in 2018.
With the 2018 elections widely expected to be a banner year nationally for Democrats, Republican lawmakers at the state level would be wise to move to the center on the issue, which has proven to be an economic boon, or face the wrath of voters come November. Not only would it allow vulnerable lawmakers to appeal to the center and potentially save their jobs, it would also allow them to create an expansion on their own terms.
States that have yet to expand Medicaid include Alabama, Florida, Georgia, Idaho, Kansas, Mississippi, Missouri, Nebraska, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin and Wyoming.