By Peter Sullivan - 11/21/15 09:14 AM EST
Supporters of ObamaCare are increasingly hopeful that Medicaid expansion could sweep through the deep-red South.
Not a single state in the lower south has accepted the standing offer under ObamaCare to expand Medicaid to people living up to 138 percent of the poverty line, which is about $33,000 for a family of four.
Sen. David Vitter (R-La.) has expressed openness to Medicaid expansion if he is elected governor of Louisiana on Saturday, and his Democratic opponent, John Bel Edwards, has been an enthusiastic supporter of expansion as well.
More recently, there was surprising news out of Alabama, as a commission appointed by Republican governor Robert Bentley recommended expansion. Bentley said earlier this month that he is "looking" at the possibility of broadening Medicaid.
"What is going to happen is that support for Medicaid expansion will continue to build," Secretary of Health and Human Services Sylvia BurwellSylvia Mathews BurwellOvernight Healthcare: McConnell unveils new Zika package | Manchin defends daughter on EpiPens | Bill includes M for opioid crisis Insurance executives ask for changes to ObamaCare Obama meets with insurance CEOs on health law MORE told Atlanta Magazine in an article published Monday. "You hear the Alabama governor. You’ve heard conversations in Louisiana."
Supporters of Medicaid expansion hope that if they can get a foothold in the South, other states will follow.
“I do think that if we have some states in that belt in the South then that will put pressure on the states around them,” said Dee Mahan, Medicaid program director at the liberal healthcare advocacy group Families USA.
Alabama is unlikely to simply expand the healthcare program as ObamaCare envisioned, but instead would likely negotiate with the administration to put a conservative twist on the program, as other Republican-led states have done.
One option is the Arkansas model, where the expansion enrolls people in private health insurance plans instead of government-run Medicaid.
Jim Carnes, policy director at Alabama Arise, a non-profit aiming to help low-income people and a member of the governor’s commission, said that something along the lines of the Arkansas model is possible. Some sort of provision related to encouraging enrollees to work is also possible, he said, though the Obama administration has so far rejected full-on work requirements.
The commission as a whole, which included state legislators from both parties, likewise proposed an “Alabama-driven solution,” indicating that some modifications to the Medicaid program could be necessary.
While those details are still to be worked out, Carnes says he sees positive signs from the governor about agreeing to some form of Medicaid expansion.
“I think he's really been pointing in that direction and will make his move in the near future,” Carnes said.
In Louisiana, Vitter has also pointed to private coverage and work-related provisions.
“Where we are now is facing a law that’s on the books and the issue of Medicaid expansion,” Vitter said last week, according to the Associated Press. “I said from the beginning of the campaign, I would not rule it out. But I would only do it on solid, sound Louisiana-terms, not on the federal government’s terms.”
One of the things pushing states towards expansion, despite the divisive politics of ObamaCare, is the infusion of federal money it provides.
Hospitals have also been strong advocates for expansion, as coverage for more people reduces the amount of care they have to provide to the uninsured without compensation.
The Alabama commission described expansion as a “win for the state budget” and noted that five rural hospitals in the state have already closed since 2011.
The clock is also ticking to take full advantage of federal funds, as 2016 is the final year that the federal government will pay for the entire cost of expansion.
In addition to the economic arguments, Bentley has also acknowledged a changed political reality.
"I was personally against the Affordable Care Act,” he said last month, according to the Alabama Media Group. “I never called it ObamaCare because it's not a person, it was a philosophy.”
"But we lost folks. We lost. And we lost in court,” he added. “So what we have to do now is move past that, take the resources we have available and try to improve the quality of life for the people of Alabama, and that's exactly what I'm going to do.”
Thirty states have taken the Medicaid expansion so far, but in some of the remaining states, including Tennessee and Utah, Republican governors are on board, but not the legislatures.
Some Republicans still have objections, often voicing concerns about the cost.
Still, in Alabama, Carnes said he hoped that Democrats and more moderate Republicans “can develop a new alliance that can overcome that hardcore opposition.”
Burwell said she has high expectations for Alabama and the rest of the country.
Asked by Atlanta Magazine whether she thought it was “just a matter of time” before all states expanded Medicaid, Burwell replied, “Yes.”