Where pragmatism about health reform lives

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In 2014, ideological battles are front and center in U.S. national politics. Revving up their base for the midterm elections, congressional Republicans are suing, investigating and denouncing full time. And a Supreme Court sharply split by ideology and gender has launched fundamental shifts in the rule of secular law. Disputes about ObamaCare, as the Affordable Care health reform law is known, are right at the heart of these national partisan divides.

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Yet when it comes to health reform implementation outside of Washington, we see a very different trend. In many states, Republicans are showing a spirit of pragmatism about compromises to enable expansion of Medicaid coverage to the near poor — and the Obama administration is meeting such health reform pragmatism halfway.

Enlarging Medicaid to include 12 to 13 million more adults with incomes just above the poverty line (according to Congressional Budget Office projections) is one of the major mechanisms for expanding health insurance coverage included in the Affordable Care Act of 2010. In June 2012, the Supreme Court turned this into a political football by ruling that state governors and legislatures could decide to accept or reject federal funding for this planned expansion without losing any previous Medicaid money. Given the leverage of Tea Party forces over Republican officeholders and candidates, most at first ostentatiously declined the Medicaid expansion. A year ago, all Democratic-led states had decided to go forward, but most states where Republicans were in charge were refusing or hanging back.

But 2014 has brought widening cracks in the previously almost-solid wall of GOP resistance. After all, a lot of money is at stake, because the federal Treasury pays the full cost of each state's Medicaid expansion through 2016, with slight declines thereafter until the subsidy stabilizes at 90 percent from 2020 onward. If federal subsidies are refused, jobs are lost, state budgets face unnecessary strains and healthcare providers and businesses lose profits and customers.

Facing such realities and urged on by hospital executives and business leaders as well as consumer advocates, Republican governors in Arizona, North Dakota, Michigan, Ohio and (most recently) Utah have pushed GOP legislatures and bucked ultra-conservative activists to devise ways to accept the full Medicaid expansion. Republican governors have also gone along with Medicaid expansion in states such as New Mexico and New Jersey where Democrats control one or both houses in the legislature. And a number of GOP legislators have allowed themselves to be persuaded in various states with divided control under Democratic governors.

Notably, even some Republican governors with aspirations to compete for their party's presidential nomination have found or are looking for ways to accept new Medicaid monies. Chris Christie expanded the New Jersey program, and Indiana Gov. Mike Pence is looking for a way to combine "conservative" reforms with acceptance of the new federal Medicaid monies. In Wisconsin, Gov. Scott Walker has devised his own unique way to take the money while denouncing ObamaCare. He has shifted 77,000 near-poor Wisconsinites who had been in his state's Medicaid program to the federal insurance exchange and replaced them with a slightly larger number of the poorest residents. This halfway, back-door Medicaid expansion is more restrictive than the Affordable Care Act envisaged, but it amounts to an implicit acknowledgement of the fiscal and humanitarian appeal of health reform.

There is even a bit of action in Texas, refusnik in chief when it comes to ObamaCare. Buried in the Affordable Care Act are new federal requirements (with 90 percent funding) for states to streamline Medicaid enrollment by automating searches of federal and state databases, updating technology and expanding the notification of citizens who are eligible. Some 45 states, including the Lone Star state, have taken these steps. As a result, even in states that have refused to expand Medicaid eligibility, tens of thousands of low-income people have newly enrolled after learning that they were eligible for coverage under their state's original Medicaid rules.

More states where Republicans hold full or partial sway are likely to jump on the Medicaid expansion bandwagon in 2014 or early 2015. In Pennsylvania and Maine, GOP officeholders are looking for compromises. And in other states, Republicans may seek federal government permission — called "waivers" — to use Medicaid money to subsidize purchases of private health insurance, as Arkansas and Iowa have done.

In general, officials in the Obama administration have both encouraged and gone along with compromises that serve to get Republicans on board with Medicaid expansion. True, some health reform advocates recoil at the prospect of "weakening" the Affordable Care Act's original approach to enlarging Medicaid as is. But Obama officials recognize that all or nothing is a bad choice when two-thirds of U.S. states are controlled in whole or in part by Republicans. Because accommodating pragmatic Republican preferences can deliver health insurance to millions of human beings who currently have no coverage, it makes good sense to encourage state-level Republicans who show willingness — and courage — to break from the rigid ideology of their Washington congressional counterparts.

By reaching out to pragmatic GOPers in the states, President Obama is hardly showing any unusual propensity for caving in. The Affordable Care law explicitly empowers federal officials to approve state-level innovations, and there is a long history of adjusting federal legislation on topics ranging from living wills to abortion and previous social insurance programs to draw states into full compliance. For example, in just the first four years after Congress passed the 1997 Child Health Insurance Program, the states implemented the law in modified ways more than 100 times. The challenge for Obama administration officials is to grant waiver requests that let Republican state officials place a few new conditions on Medicaid coverage and use federal funds to subsidize private businesses or insurance plans, without in the process compromising national Medicaid standards too much.

Waivers have already been granted to Arkansas, Iowa, and Michigan — and more are likely to come soon. The urgency is clear. The Obama administration is moving into its final phase, and research suggests that the spread of new reforms across the states often plateaus after the first five years. For both the Obama administration and Republican leaders in the states who must grapple with the realities of governing, health reform pragmatism is an appealing option, a path forward apart from the ideological storms that rage in much of national politics. The Medicaid expansion examples of reform pragmatism we have seen in 2014 are bound to spread and accelerate in the months ahead.

Jacobs is the Walter F. and Joan Mondale Chair for Political Studies at the University of Minnesota. Skocpol is Victor S. Thomas Professor of Government and Sociology at Harvard University. Both are members of the Scholars Strategy Network.