While many Americans are obsessively following the presidential primary campaign, health policy experts are concerned about little-noticed Republican primary contests for state legislative seats that could determine the fate of Medicaid expansion in Arkansas and other states.
In Arkansas, Tuesday's elections include several primary contests pitting Republican state lawmakers who voted for Medicaid expansion to low-income adults against GOP primary challengers who promise to end the state's coverage expansion. Republican Gov. Asa Hutchinson needs votes from 75% of the GOP-controlled Legislature to win approval for his conservative changes in the state's Medicaid expansion program, or else the expansion will end this year. So he can't afford to lose any expansion allies.
“It's a big-government program that Republicans need to quit supporting,” said state Rep. Donnie Copeland, who is running to unseat Republican state Sen. Jane English. She twice supported the reauthorization of the expansion spearheaded by the state's previous Democratic governor.
The main conflict in all these states is between Republicans who favor implementing or preserving expansion and Republicans who are dead set against it and denounce their pro-expansion colleagues as sellouts in the quest to repeal the Affordable Care Act. Hospitals and other healthcare provider groups are pushing to implement or keep expansion, while conservative advocacy groups led by the Koch brothers-funded Americans for Prosperity are running ads criticizing GOP lawmakers who have supported expansion.
Other states where there are legislative fights over renewing and modifying current expansion programs or terminating the programs entirely are Kentucky and New Hampshire. Meanwhile, in Republican-controlled Florida, South Dakota, Tennessee, Utah and Wyoming, which haven't yet expanded Medicaid, there are battles over proposals by Republican governors or legislative leaders to launch expansions.
In New Hampshire, a conservative group reportedly is trying to line up like-minded Republican primary challengers to run in the Sept. 13 primary against GOP lawmakers who voted for Medicaid expansion. That state's Medicaid expansion program will end in December unless the Legislature reauthorizes it, which Democratic Gov. Maggie Hassan is pushing for.
In Tennessee, Republican Gov. Bill Haslam's conservative-friendly Medicaid expansion program failed in the GOP-controlled Legislature last year, despite polls showing strong public support for it. “In Tennessee, in many House and Senate districts, people were concerned that if they supported this Obama program, it would hurt their chances of re-election against a more conservative Republican,” said Republican state Sen. Richard Briggs, a cardiothoracic surgeon who supports Haslam's proposal.
“The public overwhelmingly supports it, but the Legislature is more conservative than the state itself and won't have anything to do with it,” said John Geer, a professor of public policy who heads political polling at Vanderbilt University.
For now, Tennessee Republican lawmakers who may be sympathetic to Haslam's proposal are staying mum on the issue until April 7, the candidate filing deadline, when they find out whether they have drawn a more conservative Republican primary opponent. The primary election is on Aug. 4. “Even legislators who understand why Medicaid expansion is so important are terrified of being primaried,” said Michele Johnson, executive director of the pro-expansion Tennessee Justice Center.
There's an added wrinkle in Tennessee that complicates the Medicaid expansion fight. The state receives $500 million to $600 million a year in federal funding for a low-income care pool that compensates hospitals for treating indigent patients. That funding will end in June unless the Obama administration renews it. The administration made clear in a clash with Florida state officials last year that in deciding whether to renew this funding, it will consider whether a state has expanded Medicaid. HHS officials argue that if a state accepts Medicaid expansion, there is less need for a low-income pool because hospitals can receive Medicaid payment for many of these patients.
So Tennessee's action or inaction on Medicaid expansion during the current session could affect the renewal of the low-income pool. “I'm hearing from reliable sources that the money is going to be gone or we may get a tiny percentage,” Johnson said. “Hospitals need to assume they won't get 100% of that money starting July 1, or they may not get any of it.”
The positions on Medicaid expansion that state legislative candidates take in primary contests matter, said Tim Storey, elections analyst at the National Conference of State Legislatures. “One thing you can guarantee is that both Republicans and Democrats, when they run on these things, they hold to them,” Storey said.