Senate Republican leaders apparently have persuaded wavering GOP senators from Medicaid expansion states to support a fast-track bill that would repeal Medicaid expansion along with most of the rest of the Affordable Care Act.
They must be calculating that people who have benefited from the expansion don't vote.
The so-called reconciliation bill, which may be voted on Thursday, reportedly would phase out the expansion of coverage over two years to low-income adults with incomes up to 138% of poverty.
The bill was crafted to win the support of a trio of conservative senators who demanded a more complete ACA repeal than the House version offered. It also would kill the ACA's premium subsidies for buying private insurance, along with the medical-device tax and the so-called Cadillac tax on high-value employer health plans. The legislation, which will certainly be vetoed by President Barack Obama, would at last fulfill the Republican promise to pass a bill killing the ACA. The Republicans will not be able to muster a two-thirds vote in both chambers to override Obama's veto.
Thirty states plus the District of Columbia have agreed to the Medicaid expansion; Medicaid and Children's Health Insurance Program coverage grew by more than 14 million, largely due to the ACA, according to a new report from the Medicaid and CHIP Payment and Access Commission.
Republican senators from some states that have expanded Medicaid previously expressed reservations about repealing the Medicaid coverage expansion, which has benefited thousands of their constituents and been strongly supported by hospital and business groups.
“I am very concerned about the 160,000 people who had Medicaid expansion in my state. I have difficulty with that being included,” Sen. Shelley Moore Capito (R-W.Va.) told The Hill newspaper.
Sen. Steve Daines (R-Mont.) told The Hill, “I respect the decision of our legislators and our governor on Medicaid expansion.”
But after doing some serious arm-twisting last weekend, GOP leaders are expressing confidence they have won over the holdouts and can deliver the 51 votes needed to pass the reconciliation bill. Capito's office says the West Virginia senator is now prepared to vote yes on the ACA repeal bill, including the phase out of federal funding for Medicaid expansion. A Capito spokeswoman noted that the Senate bill would establish “a transitional period to allow for alternative reforms to come into play.” The spokeswoman added that Capito would like to see “alternative reforms that improve access and lower costs without disrupting coverage.”
Of course, it's not clear what those “alternative reforms” would look like exactly under a Republican president and GOP-controlled Congress in 2017. Republicans generally talk about turning Medicaid into a capped block-grant program that would give states a fixed amount of money and offer them great flexibility to determine who is eligible for the program and what benefits to cover. Advocates for Medicaid patients warn that under that proposal, fewer people would be covered by skimpier benefit plans, and they would be required to pay more out of pocket.
A spokeswoman for Daines said the Montana senator will support the GOP reconciliation bill repealing Medicaid. While he respects his state's decision to expand the program, the spokeswoman said Daines has “concerns about the long-term sustainability” of the expansion “and is wary of programs that increase the power Washington may have over the states.” In Montana, an estimated 55,000 people are eligible for expanded Medicaid.
There was no immediate response to a request for comment from Sen. John Hoeven (R-N.D.), whose state also has expanded Medicaid and who also previously expressed doubts about repealing the Medicaid expansion. In North Dakota, an estimated 19,000 people are eligible for expanded Medicaid.
Nor were there immediate responses from Sen. Mark Kirk (R-Ill.) or Sen. Rob Portman (R-Ohio), whose states expanded Medicaid and who both face tough re-election contests in 2016. Illinois has an estimated 572,000 people eligible for expansion, while Ohio has an estimated 454,000 eligible.
Voting to repeal the ACA's Medicaid expansion also could cause political headaches for GOP incumbents in close races in other Medicaid expansion states such as Pennsylvania (379,000 eligible) and New Hampshire (35,000 eligible). Their Democratic opponents undoubtedly would run campaign ads saying they voted to take away people's healthcare.
Nearly a third of the 30 states that have expanded Medicaid did so under Republican leadership, and GOP leaders in several other states, such as Alabama Gov. Robert Bentley, are discussing expansion. Two GOP presidential candidates, Gov. John Kasich of Ohio and Gov. Chris Christie of New Jersey, have supported expansions in their states. The state expansions have brought billions of federal dollars into those states, significantly reduced the uninsured rate, and financially boosted the healthcare industry.
The GOP senators from Medicaid-expansion states who plan to vote for this repeal must be hoping that the tens of thousands of constituents who may lose their coverage don't vote. They may be thinking about last month's Kentucky gubernatorial election, in which Republican Matt Bevin, who vowed to roll back his state's Medicaid expansion, easily defeated a Democrat who promised to protect it.
Even though the expansion extended coverage to about 425,000 Kentuckians and helped halve the state's uninsured rate, many of those who benefited from the expansion in poor communities such as eastern Kentucky didn't vote. According to a New York Times report last week, many Medicaid patients didn't even know that the issue of taking away their coverage was being discussed.