Texas, for instance, has been known as a state fervently opposed to the coverage provisions of the Patient Protection and Affordable Care Act, as evidenced by the hostility of GOP Gov. Rick Perry. But even in Texas, the report notes, bipartisan legislation has been introduced that would allow federal funds to be used to expand Medicaid by subsidizing the purchase of private plans by low-income households, essentially a take on the private option pioneered by Arkansas.
“There's a lot of talk about a Texas solution, but there's not much concreteness about that,” David Werner, a health policy expert at the University of Texas Austin, said during an event Monday in Washington to discuss the findings of the report. He indicated that the federal government might need to “loosen” the rules regarding expansion to entice more states to participate.
By contrast, Kentucky has been widely held up as the rare southern state fully embracing the federal healthcare law. The state's uninsured rate has dropped from 20.4% to 11.9% since last year, according to Gallup, a dip exceeded only by Arkansas.
But the expansion of Medicaid to individuals with incomes up to 138% of the federal poverty threshold was authorized through an executive order by Democratic Gov. Steve Beshear, who's scheduled to leave office in January 2016. Depending on who succeeds him, the embrace of Obamacare could be reversed.
The dynamic also has the potential to move in the opposition direction, the report noted. Virginia Gov. Terry McAuliffe, a Democrat, has moved aggressively in attempts to expand Medicaid since being elected last year, a reversal of the stance of his Republican predecessor. While McAuliffe hasn't been able to garner support from the GOP-controlled Legislature, he is exploring the possibility of expanding Medicaid through executive action.
In addition, decisions about whether to implement key provisions of the healthcare law in southern states have not necessarily been driven simply by political opposition to Obamacare. In West Virginia, the state opted to expand Medicaid but also decided to largely default to Healthcare.gov for enrollment. The decision not to establish a state-based exchange, however, was made largely because state officials didn't believe it would be financially viable given the lack of competition in the insurance market in West Virginia.
“It's not been a hostile position,” said Christopher Plein, a public policy expert at West Virginia University. “It's been more of a passive position.”
Hospitals continue to exert pressure on officials to expand Medicaid in southern states. Trade associations in Alabama, Florida, South Carolina and Texas have been particularly vocal on the issue, according to the report.
The dynamics in each state are different, noted Alice Rivlin, a senior fellow at the Brookings Institution and a former director of the Congressional Budget Office, in part because insurance is largely regulated at the state level. “This whole thing is full of surprises,” Rivlin said.
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