Voters not only stopped the Medicaid expansion dead in its tracks on Tuesday night, they elected Republican candidates vowing to change or roll back Medicaid in states that have already expanded.
In the most closely watched contests, Gov. Scott Walker in Wisconsin, which has rejected federal funds to expand Medicaid to cover the near-poor, handily won re-election over Democratic challenger Mary Burke. And in Arkansas, whose private-sector run Medicaid option received federal backing, newly elected Asa Hutchinson has vowed to put new limits on a program that has meant coverage for more than 200,000 residents with no other options.
“I view the private option as a pilot project; a pilot project that can be ended if needed,” Hutchinson said on his campaign website. “As governor, I will assess the benefit of the private option and measure the long-term costs to the state taxpayers.”
In the biggest surprise of the evening, GOP candidates also won the governor's mansions in Illinois, Maryland, and Massachusetts—Democratic strongholds that have already expanded the program. These and other states could see efforts to scrap their expansion for options like those granted by the CMS in Arkansas, Michigan and Arizona.
On the eve of the election, administration officials seemed to recognize they would face a more hostile landscape in statehouses across the country in 2015. HHS Secretary Sylvia Mathews Burwell told the National Association of Medicaid Directors on Tuesday that “your state can choose to expand at any time. You also reserve the right to change your mind.”
In making the case for expansion, she shared an anecdote about a man in Maryland who was able to receive coverage because of the program. Yet voters in that state, where registered Democrats outnumber Republicans by a 2-to-1 margin, elected Republican Larry Hogan over Democrat Anthony Brown.
During his campaign, Hogan criticized Brown's role in embracing the Patient Protection and Affordable Care Act by touting the horrors of the rollout of Maryland's healthcare exchange. However, Medicaid wasn't a major focus of the campaign. Instead, Hogan hammered away at the tax increases granted by Brown's former boss, Democratic Gov. Martin O'Malley, whose presidential ambitions suffered a serious blow on Tuesday night.
In Illinois, Governor-elect Bruce Rauner has been upfront about saying he would have vetoed any legislation expanding Medicaid had it come to his desk. However, he has also said he would not rollback the program if elected.
Rather, he has hinted that he may scrap the state's more traditional expansion in favor of a different approach. “I am advocating and always have and always will (that) we've got to restructure Medicaid in Illinois. It is filled with waste and fraud,” Rauner said last month.
Fellow Republican Charlie Baker, who defeated Democrat Martha Coakley in Massachusetts, has also hinted that he will seek a federal waiver to make changes in his state's Medicaid expansion. “I'd like to be in a situation where the commonwealth can actually advocate for its own interests if . . . (it) fits within some framework that relates to the goals and objectives of the Affordable Care Act,” Baker said recently.
He may seek a Medicaid waiver to increase pay for primary-care doctors. “If we simply invested in primary care,” Baker said, “we would spend less on healthcare overall, and we'd have healthier, happier people.”
Meanwhile, states that failed to expand Medicaid saw that stance vindicated. Maine Gov. Paul LePage, who has vetoed legislation to expand the program on five occasions, successfully beat back a challenge from Democrat Mike Michaud, who actively campaigned in favor of expansion.
Gov. Nathan Deal, who won re-election in Georgia, has been on the record as not being interested in expanding. The same goes for the victorious Scott Walker in Wisconsin.
In two important bellwether states—Florida and Arizona—voters opted for the status quo. Gov. Rick Scott of Florida, which has failed to expand Medicaid, won re-election by a narrow margin to Democrat Charlie Crist. Scott has expressed interest in expanding the program, but never proposed legislation and didn't campaign on it.
In Arizona, where outgoing Gov. Jan Brewer went along with a home-grown Medicaid expansion plan while attacking the reform law, GOP Governor-elect Doug Ducey has expressed doubts about the program. But he also said he would seek its repeal only if the federal match drops significantly. The law eventually reduces federal matching funds to 90% of the cost of the program.
Democratic supporters of reform generally and Medicaid expansion in particular did manage a few victories on Tuesday. In Pennsylvania, Tom Wolf defeated Republican Gov. Tom Corbett. The victory could mean that Wolf will scrap Corbett's recent-granted Medicaid waiver for a straightforward expansion.
In Rhode Island, Gina Raimondo won the governor's mansion in a close race against Republican Allan Fung. More than 60,000 people in the state have joined Medicaid since the reform law went into effect.
Expansion will also stay intact in Kentucky, where Democrats maintained control of its House of Representatives.
Follow Virgil Dickson on Twitter: @MHvdickson