Reform Update: Governor races could be referendum on ACA, Medicaid expansion

With governor races in 36 states this fall, new faces in several governors' chairs could influence states' stances on Patient Protection and Affordable Care Act implementation and Medicaid expansion.

Key races to watch include Pennsylvania and Maine, where a party switch for the office could boost expansion. In Republican-controlled states like Texas, Georgia and Florida however, there's less likelihood for Medicaid expansion, regardless of who wins the governor's race.

In Pennsylvania, Republican Gov. Tom Corbett may have a tough race this November. All four of the current Democratic candidates have come out vehemently against his Healthy Pennsylvania healthcare proposal. The Democratic primary takes place May 20.

The Healthy Pennsylvania proposal includes a Medicaid expansion provision that would provide funds for people to buy private insurance rather than receive direct Medicaid coverage. Opponents have said Corbett's efforts to obtain a federal waiver to support the proposal's funding are simply delaying Medicaid coverage for half a million people.

G. Terry Madonna, director of the Center for Politics and Public Affairs at Franklin & Marshall College, said that all the state's Democratic candidates support Medicaid expansion, rather than Corbett's hybrid approach.

The Republican-controlled Pennsylvania Senate passed Medicaid expansion last year, but the state house, which is more conservative, has not, Madonna noted. Whether a new Democratic governor could sway those votes for Medicaid expansion is an open question.

In Maine, the Democratic-controlled state legislature has been battling with Republican Gov. Paul LePage to expand Medicaid. On April 17, the legislature voted for the third time since March in favor of Medicaid expansion, but the bill is likely to be vetoed by LePage, as he has done twice before.

Currently, Democratic state representative Mike Michaud, who is running for governor in Maine, has come out in support of Medicaid expansion, and is leading LePage by a few points in recent polls.

“So if the governor changes, and the new governor has a different opinion about the Medicaid expansion, and the legislature stays with its current composition, the governor could make a very big change,” said Anne Gauthier, senior program director at the National Academy for State Health Policy.

In Texas, Republican Gov. Rick Perry has been strongly opposed to the ACA and Medicaid expansion. With Perry leaving office, Republican state Attorney General Greg Abbott and Democratic state Senator Wendy Davis are vying for the seat, with Abbott in the lead. Abbott has said he also is against Medicaid expansion, while Davis supports it.

James Henson, a lecturer in the department of government at the University of Texas at Austin, contended that there is some bipartisan support bubbling up in the state for Medicaid expansion, but Republicans in favor of it are loathe to make a public declaration.

“There are business folks who have advocated for the Medicaid expansion because they think it makes financial sense. There's an argument that the federal match is a good deal,” he said.

But Henson added that, if Abbott wins, he doubted Medicaid expansion would occur. “I think there's still a pretty strong wellspring of fear in the Republican Party that anybody who votes for Medicaid expansion will then have to face opponents accusing them of supporting Obamacare,” he said.

Illinois expanded Medicaid in July 2013, one of the first states to do so, and has signed up more than 300,000 people so far, said Linda Baker, a professor at Southern Illinois University.

Current Democratic Gov. Pat Quinn created a state-based healthcare insurance exchange called Get Covered Illinois in October 2013. Quinn's opponent for governor, Republican businessman Bruce Rauner, has not taken a strong stance against Medicaid expansion thus far.

Two strongly Republican-controlled states, Georgia and Florida, are not likely to see big changes in healthcare exchange offerings or Medicaid expansion after their elections this fall.

In Georgia, incumbent Republican Gov. Nathan Deal has declined federal funding to expand Medicaid, while Democratic opponent Jason Carter, Jimmy Carter's grandson, has supported such expansion. But Carter is not favored to win the race.

However, if Deal wins, he could change his position on Medicaid because he would have reached his two-term limit and wouldn't be worried about another reelection campaign, said Steve Anthony, lecturer in the political science department at Georgia State University. “It wouldn't surprise me if he softened up on some of these provisions since he wouldn't face reelection again,” he said.

As for a Georgia state-based healthcare exchange, Anthony said Democrats may debate it, but he doesn't see support for it from a Republican governor.

In Florida, where incumbent Republican Gov. Rick Scott is running against former Republican-turned-Democrat Charlie Crist, “From a healthcare perspective, it doesn't really matter who gets elected. At the end of the day, Florida is a weak governor model. All the power really rests in the hands of the legislature,” said Bob Jarvis, a professor of law at Nova Southeastern University.

“The legislature is in the firm control of Republicans and the legislature has no interest in providing healthcare to the poor, or expanding any sort of healthcare,” he said.

Rebecca Kern is a Washington, D.C.-based freelance journalist.