Florida and North Dakota have very different political and financial dynamics from each other and from the three other states—Michigan, Ohio and Arizona—where Republican governors are pushing expansion to Republican legislators.
For instance, legislators are term-limited in Florida but not in North Dakota. Additionally, Florida has had a relatively stable federal matching rate for Medicaid, which is dually funded by state and federal governments. However, the federal share reached about 70% in North Dakota during the recent recession before dropping down to 50% after a recession-related federal boost expired.
“So in North Dakota, they had experience with getting a higher federal match for Medicaid and understand the benefit of that,” said Patrick Willard, senior legislative representative at AARP, which is leading the expansion push in many states. “That was one of the arguments that was used by proponents of it.”
Meanwhile, Florida's legislative session ended May 3 with the chamber's Republicans deadlocked over a Senate bill backed by Scott—and closest to a standard expansion in under the federal law—and a competing plan for a smaller coverage expansion backed by House Republicans.
That intraparty stand-off over different Medicaid plans was somewhat unusual, said Joy Wilson, health policy director for the National Conference of State Legislatures.
“In some of the other states, there was one piece of legislation that was controversial,” Wilson said in an interview. “It's kind of different when you have leadership on one side and leadership on the other side having a dramatically different approach.”
A similar dynamic may be emerging in Michigan, where Republican Gov. Rick Snyder is pushing a Republican-led legislature to undertake the expansion. On May 9, House Republicans proposed an expansion of Medicaid eligibility that included some elements opposed by the governor, including limiting healthy adults to four years of coverage.
Lawmakers touted the time limit as the first such proposal in the country, but it could draw opposition from the CMS, which has repeatedly indicated there are limits to the flexibility it would allow states as part of their Medicaid expansions.
Supporters of the expansion, including the state's hospitals, described the bill as starting point.
“We are encouraged by provisions in House Bill 4714 that would lower Medicaid costs, protect Michigan taxpayers and job providers from future decisions made in Washington, and require more personal responsibility from new Medicaid enrollees,” Spencer Johnson, president of the Michigan Health & Hospital Association, said in a written statement. “The MHA thanks legislators for starting the process of developing Medicaid reforms that take the program from good to great, while providing access to insurance to thousands of uninsured Michigan workers.”
Other provisions of the legislative proposal include the use of health savings accounts for Medicaid enrollees and allowing them to choose between the traditional Medicaid program or buying their own coverage on the coming health insurance exchange.
Michigan's Medicaid expansion clash is more active than the Ohio push by Gov. John Kasich. That legislature has designated a group to study the expansion and report back sometime later this year.
Finally, the intraparty battle over Medicaid may be coming to a head in Arizona, where Gov. Jan Brewer recently declared that she will sign no new bills into law until the Republican legislature approves a budget that includes a Medicaid expansion.