Medicaid advocates frustrated by red-state holdouts

The politics of Medicaid expansion are changing as an increasing number of red states are dropping their opposition, but for expansion advocates there is also increasing frustration at the remaining holdouts. 

To date, 36 states and the District of Columbia have adopted Medicaid expansion, including a handful of conservative strongholds.

Just last week, Kansas’s first-term Democratic Gov. Laura Kelly announced a bipartisan compromise with Republican state Senate Majority Leader Jim Denning to pave the way for Medicaid expansion.

“This proposal embraces Democratic priorities and Republican priorities,” Kelly said at a press conference. 

President Trump won Kansas by more than 20 points in 2016, but Kelly ran on a promise to expand Medicaid, and defeated hardline Republican and Trump ally Kris Kobach last November. 

The state’s former Republican governor Sam Brownback vetoed Medicaid expansion legislation in 2017, and the veto was narrowly upheld in the legislature.

The deal would expand Medicaid to cover as many as 150,000 more people and would make Kansas the 37th state to expand Medicaid under ObamaCare. 

Notably, it does not include work requirements. Instead, it includes a program to help refer people for jobs and help them gain employment, without taking away their Medicaid coverage if they do not. 

Similar legislative compromises have been reached in Kentucky and Louisiana, and voters approved Medicaid expansion in Utah, Idaho and Nebraska in 2018. 

The bipartisan success of red state Medicaid expansions has advocates in the remaining 13 holdout states arguing that pure partisanship is getting in the way of helping people.

Under ObamaCare, the government will pay no less than 90 percent of the costs for a state to expand Medicaid to people earning up to 138 percent of the federal poverty level, or about $36,000 for a family of four. 

“We’re certainly reaching a boiling point here, that Republican leadership has not been able to come to the table on Medicaid expansion,” said Hyun Namkoong, a policy advocate with the North Carolina Justice Center’s Health Advocacy Project.

“People that can’t access healthcare because of the politics of the issue is really frustrating. Especially when we see states like Kansas that can work out a compromise,” she added.

In North Carolina, the efforts of Democratic Gov. Roy Cooper on Medicaid expansion have been stymied by the Republican-controlled legislature. Cooper vetoed the state budget in June primarily because it did not expand Medicaid. 

Advocates expected state legislators to take up expansion legislation this week during a special session, but instead lawmakers adjourned until April after meeting for only three hours. Legislators adjourned after failing to override Cooper’s veto of the budget.

Cooper and state Democrats have vowed to make expansion an issue in the 2020 election, but advocates want action now. 

Peg O’Connell, chairwoman of the Care4Carolina coalition, said the fact that other states were able to find bipartisan compromise on expansion should send a message to North Carolina Republicans.

“Clearly it’s not political suicide to come to some sort of agreement on this issue, whether you’re a Democrat or a Republican. People who want to find a solution, regardless of party affiliation, can find a solution,” O’Connell said. 

Health care and political analysts think the opposition to Medicaid expansion is waning in red states, but it hasn’t completely disappeared.

Cindy Mann, a partner at Manatt Health who ran the Medicaid program under former President Obama, said the last four to five years have seen “a steady march” of states moving to expand Medicaid.

“We haven’t seen one state where an election has resulted in an expansion rollback, even if it changes from blue to red. But we have seen elections pushing expansions forward,” Mann said. 

“When it’s a steady march, the holdouts are very much the exception, and how long they can maintain that remains to be seen,” she said. 

Still, Mann said the “strong opposition” to Medicaid expansion in a number of states should not be overlooked.

Republicans in the holdout states may also not be feeling the same political pressures.

“I think the politics of expansion have trended towards a more Democratic posture, but in Republican states, their voters expect their leaders to improve the program … Republicans want to see improvements, they are not interested in just a straight expansion,” said Marie Sanderson, a former policy director at the Republican Governors Association.

Sanderson, currently a partner at the public affairs firm 50-State, said the holdout states need to do a better job at explaining why they won’t expand Medicaid.

“There are well-founded reasons that are popular if communicated in the right way,” Sanderson said. “But Republicans have had a hard time making those policy reasons resonate with voters. It’s not just ‘no’ but ‘no because there’s a better way.’” 

Jerry Vitti, CEO of Healthcare Financial, a firm that helps connect low-income beneficiaries to disability benefits, said he doesn’t necessarily see the deep red holdout states shifting anytime soon. 

Yet Vitti said the compromise in Kansas can still be helpful.

“One more domino going down can help get the energy moving for other Republicans thinking about expansion,” Vitti said. 

Updated on Jan. 23 at 12:55 p.m.

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