The Affordable Care Act took a political drubbing Tuesday, with voters rewarding Republican candidates in Kentucky and Virginia who strongly opposed the law's coverage expansions.
In a closely watched election in Kentucky, Republican businessman Matt Bevin bested Democratic Attorney General Jack Conway to become the state's next governor. He will succeed popular two-term Democratic Gov. Steve Beshear, who spearheaded Medicaid expansion and the creation of a state-run insurance exchange, called Kynect.
President Barack Obama has pointed to Kentucky as one of the law's biggest success stories. The ACA coverage expansions there cut the state's uninsured rate by more than half, to less than 10%. The hospital industry has benefited financially from having to provide less uncompensated care. About 400,000 lower-income Kentucky adults have qualified for Medicaid coverage under the Affordable Care Act, and approximately 100,000 more signed up for private plans through Kynect, according to state data.
But some Kentucky political observers say Bevin's surprisingly lopsided win may not be as negative for Medicaid expansion as Obamacare supporters had feared.
Meanwhile, GOP victories in Virginia's state legislative elections very likely killed Democratic Gov. Terry McAuliffe's immediate prospects of Medicaid expansion there.
ACA supporters are concerned that these election results offer Republicans political encouragement to campaign aggressively against the law heading into the 2016 presidential and congressional elections.
The Kentucky and Virginia ballot results come just days after Montana won Obama administration approval for its Medicaid waiver, becoming the 30th state to expand eligibility under the Affordable Care Act to adults with incomes up to 138% of the federal poverty level.
Nationally, Medicaid expansion is still in play in Louisiana, where all the leading candidates in the Nov. 21 gubernatorial election have said they would consider some form of expansion. Alabama's Republican governor also hinted recently that he is considering expansion. In addition, in Kansas there is growing pressure from the hospital industry and some legislative Republicans to get the state to expand eligibility.
During Bevin's campaign in Kentucky, healthcare providers and ACA supporters were worried because he said he would roll back Medicaid expansion in the state and junk the successful state exchange—which he called a “disaster”—turning ACA enrollment over to the federal exchange. The state exchange and Medicaid expansion are popular in Kentucky, though the Affordable Care Act is not.
Glen Mays, a professor of health services at the University of Kentucky, said Bevin won despite his promise to roll back Obamacare—or Beshearcare, as Kentucky Democrats preferred to call it—because the lower-income people benefiting most from the coverage gains are not politically engaged and don't vote at a high rate. In contrast, he said, “opponents of ACA were more likely to be activated by this governor's race and more likely to turn out.”
Bevin, a wealthy investment manager, beat his Democratic opponent by a rout, 52.5% to 43.8%, with a third candidate getting the remaining votes. Just over 30% of registered voters cast ballots.
Some observers have argued that the collapse last month of the Kentucky Health Cooperative, a not-for-profit co-op plan created under the ACA, helped Bevin. He had argued that it demonstrated the failure of the healthcare reform law. The plan's closure means about 51,000 Kentuckians must switch to another health plan for 2016.
It's possible that people who have benefited from Medicaid expansion would have voted in larger numbers if they had known Bevin's position on the Medicaid issue, said David Contarino, a Kentucky-based political strategist who works with Democrats. “Although discussed during debates, it was never really part of (Bevin's) paid media program,” he said. “Perhaps if it were truly understood by the voters what Bevin intends to do, many more people would have realized the stake they had in this campaign and turned out to vote against Bevin. “
After Bevin unexpectedly won the Republican primary, his Medicaid anti-expansion stance began to soften. Facing widespread criticism, he backtracked, saying he would allow those who have gained coverage to stay in the program while capping enrollment. Then he shifted again and stated he would seek a Medicaid expansion waiver similar to Indiana's, which imposes cost-sharing on beneficiaries.
His shifting positions have prompted some observers to question if Bevin will push for any changes the current expanded Medicaid program. “Campaign promises are different from the work of governing,” said Nicole Huberfeld, a law professor at the University of Kentucky. “Kentucky's Medicaid expansion has been popular with the people of the state. While it is possible for the new governor to change the healthcare landscape in Kentucky, I would be surprised if he undoes all of the work that the Beshear administration has performed so well.”
But Greg Stumbo, the Democratic speaker of the Kentucky House of Representatives, told the Washington Post he was prepared for a tough fight to defend Kynect and the ACA coverage expansions. “I'm going to fight for Kynect because I believe it would be inhumane to take health insurance away from hundreds of thousands of people,” he said. “It's gonna be a battle in this next session to see what happens with that program.”
The Kentucky Medical Association said it's understood that Bevin will spend some time working out details of his plans regarding Medicaid expansion and Kynect, and that it plans to be part of the discussions. The Kentucky Hospital Association issued a similar statement.
In Virginia, all 140 seats in both chambers of the Virginia General Assembly were up for election. Democrats needed to pick up just one Senate seat to gain effective control of the state Senate, which would have given McAuliffe greater political leverage to push for expansion. But Republicans held control of both chambers. If the state expanded coverage, as many as 400,000 low-income Virginia adults could gain coverage, and the state could receive up to $14 billion in additional federal funds by 2022, the Urban Institute estimated last year.
“By holding onto the Senate, Republicans have ensured that Medicaid expansion will not happen in Virginia in the near future,” said Geoffrey Skelley, a political analyst at the University of Virginia Center for Politics. “Had Democrats taken back the Senate, it would have at least forced the issue to be a part of the General Assembly's upcoming budget debate. With the status quo preserved, Medicaid expansion will not get any traction.”