In North Carolina, “it would be much more likely we'd have Medicaid expansion if the Democrat wins,” said Andrew Taylor, a political science professor at North Carolina State University. “I don't think the Republicans will lose their majority in the Legislature, but the presidential race makes it a little volatile.”
Two gubernatorial races last fall showed how a party changeover can powerfully affect Medicaid expansion. In Louisiana, Democrat John Bel Edwards succeeded a fervently anti-Obamacare Republican and promptly issued an executive order expanding Medicaid to an estimated 375,000 low-income Louisiana adults who qualify. In Kentucky, Republican Matt Bevin succeeded a pro-Obamacare Democrat and quickly moved to impose tougher conditions on eligibility and benefits in the state's expansion program. He has threatened to end it if the Obama administration doesn't accept his proposal.
But some observers say a bigger factor than gubernatorial races would be a Clinton victory in the presidential race. “If Clinton wins, that will put a lot of questions about the future of the ACA to rest, and many states will re-look at the issue of expansion,” said Joan Alker, a Medicaid policy expert at Georgetown University. A Clinton victory, she added, would embolden more pragmatic GOP leaders who have been interested in expansion all along, such as Senate leaders in Florida and the governors of Georgia and South Dakota.
Democratic gubernatorial candidates in Missouri, North Carolina and Utah are arguing that the Republicans who currently control most of the levers of power in their states have hurt their residents by turning down the ACA's federal contributions to expand coverage to adults with incomes up to 138% of the poverty level.
“Two billion dollars a year. That's how much our state legislature is throwing away by refusing to expand Medicaid,” said Missouri Attorney General Chris Koster, who's currently outpolling his Republican opponent Eric Greitens in the race to succeed Democratic Gov. Jay Nixon. The incumbent, who can't run again because of term limits, tried in vain to get the GOP-dominated Legislature to approve expansion, which could benefit an estimated 253,000 Missourians. “We simply can't afford not to act,” Koster added.
In North Carolina, where Republican Gov. Pat McCrory and Democratic Attorney General Roy Cooper are locked in a tight race, Cooper has attacked McCrory for blocking expansion based on conservative ideology. The governor has suggested he's willing to consider it but the GOP-dominated Legislature has balked at extending coverage to the estimated 377,000 low-income residents who would qualify. “I know that expanding Medicaid will create jobs and save lives,” Cooper said. “Hundreds of thousands of uninsured North Carolinians shouldn't have to wait for the next governor to take action.”
In Utah, where Democrat Mike Weinholtz is trailing Republican Gov. Gary Herbert, Weinholtz has assailed the governor for “politicizing” the Medicaid expansion issue, which could benefit an estimated 116,000 adults. Herbert, who tried and failed to get the GOP-controlled Legislature to approve a conservative expansion model, said “expansion of Obamacare is a problem” for voters.
Montana, New Hampshire and North Dakota are states where Democratic candidates are fighting to protect their Medicaid expansions. In Montana, Democratic Gov. Steve Bullock, who pushed a conservative version of expansion through the GOP-controlled Legislature, is in a close race with Republican Greg Gianforte, who previously has backed groups opposed to expansion.
“If Bullock is re-elected, Medicaid expansion is here to stay,” said Jeremy Johnson, an associate professor of political science at Carroll College in Helena, Mont. “If Gianforte wins, he's expressed some qualified skepticism.”
In New Hampshire, which implemented a conservative version of expansion, Republican Chris Sununu, who previously opposed expansion, is in a tight race with Democrat Colin Van Ostern. They're vying to succeed Democratic Gov. Maggie Hassan, who steered expansion through the Legislature in 2014 and is now running for U.S. Senate. Sununu now says he wants to impose work requirements on Medicaid expansion enrollees and move people out of the program.
“It's hard to say what Sununu would do,” said Wayne Lesperance, a political science professor at New England College in Henniker, N.H., who noted that Democrats are poised to make gains in state legislative races because of the Trump effect. “Part of his caginess is waiting to see what the Legislature looks like after the election.”
North Dakota expanded Medicaid under Republican Gov. Jack Dalrymple and a GOP-controlled Legislature in 2014. Republican Doug Burgum, who's expected to beat Democrat Marvin Nelson in the race to succeed Dalrymple, has sharply criticized the ACA and the Medicaid expansion. He has called it a big taxing and spending program that's bad for the state.
The biggest prizes for Medicaid expansion supporters would be Democratic gubernatorial victories in Missouri and North Carolina, where Republican lawmakers have firmly rejected expansion under the ACA up to now. The Missouri Legislature overwhelmingly approved a recent, narrower expansion for people with disabilities or who are 65 or older. And North Carolina is in the midst of a major overhaul of its Medicaid program.
Even if Democratic governors are elected in those two states, political observers are skeptical that GOP lawmakers will reverse course and embrace expansion. “Maybe Koster, who used to be a Republican, could work with some of the Missouri Republicans,” said Thomas Ringenberg, a political science professor at Rockhurst University in Kansas City, Mo. “But the Affordable Care Act taint still prevents a lot of Republicans from supporting expansion.”
After the election in North Carolina, “if a chastened Republican majority is facing a Democratic governor who wants to do expansion and it senses that other Republicans across the country are signing up, it's plausible,” North Carolina State's Taylor said. “But Republican positions may dig in even deeper if we have a President Clinton.”