Donald Trump's reported selection of Mike Pence as his running mate means the Indiana governor will be in the position of calling for repeal of his own Medicaid expansion, which has extended coverage to more than 300,000 low-income adults.
Pence, a strong opponent of the Affordable Care Act, nonetheless pushed through a conservative version of Medicaid expansion in his state that took effect last year. His Healthy Indiana 2.0 plan—which includes premium contributions, health savings accounts, incentives for healthy behaviors, and a benefit lock-out for people who don't pay premiums—has become a model for conservative Republican governors in other states such as Kentucky and Arkansas. He currently is battling the CMS over the agency's proposal to conduct an independent evaluation of how the Indiana waiver model has affected beneficiaries' access to care. He has touted the program as a big success.
Trump, the presumptive Republican presidential nominee, has laid out a brief, seven-point healthcare proposal that would fully repeal the ACA, including the Medicaid expansion, and turn Medicaid into a capped state block-grant program. A recent House Republican leadership proposal, which may be rolled into the GOP party platform, would give states far greater flexibility to determine who's eligible for Medicaid and what the benefits would be. Experts say it would be difficult or impossible to maintain the Medicaid expansion after repealing the ACA's revenue-raising provisions.
Trump's reported selection of Pence raises the question of whether Medicaid expansion is now less politically toxic among Republicans than it used to be. Even though polls have found that most Republicans in states that have not expanded are favorable toward expansion, GOP presidential candidates and congressional Republicans almost universally oppose it. Trump himself has repeatedly criticized House Speaker Paul Ryan and other GOP leaders for seeking to cut Medicaid and Medicare.
Pence has never used the kind of emotional language to support Medicaid expansion to poor people that Ohio's Republican Gov. John Kasich used before and during his unsuccessful presidential run. Instead, Pence has focused on reforming the program along conservative, cost-saving lines. “If and when we elect a president and Congress willing to give Medicaid back to the states as a flexible block-grant, I'm confident that states will craft programs—like the Healthy Indiana Plan—that empower low-income Americans to take control of their own health-care choices and provide them access to quality care," he wrote.
If Pence is selected, “it wouldn't signal any marked change in how Republicans feel about the ACA or Medicaid expansion” because Trump's policy is to roll back Medicaid expansion and Pence as vice president would follow that policy, said Douglas Holtz-Eakin, a former adviser to John McCain's presidential campaign in 2008 and a former director of the Congressional Budget Office. He doesn't expect any Republicans to call out Pence over his decision to expand Medicaid.
If he is challenged by conservatives, Holtz-Eakin said, “Pence will say, 'I did what I thought was best for Indiana. I didn't have the opportunity to change the ACA in the past, but now we will have that opportunity.' ”
Robert Blendon, a professor of health policy and political analysis at Harvard University, said Pence's actions on Medicaid won't be a factor among Republicans because Medicaid ranks low among voting issues.
Far more relevant from Trump's perspective is that Pence has strong support among conservative religious voters based on his very conservative positions on abortion, Planned Parenthood, guns and other social issues, and Trump badly needs to shore up his own position with those voters, Blendon said.
In March, Pence signed a bill he strongly supported which, among other things, will hold physicians liable if they provide an abortion to a woman solely because of objections to the fetus's race, sex, or a disability such as Down syndrome.
“There always will be complaints about Pence expanding Medicaid,” said Joe Antos, a health policy expert at the conservative-leaning American Enterprise Institute. “The defense is he didn't just expand a welfare program, he included requirements for work, personal responsibility, and saving. That's as good an argument as it gets for a Republican.”