An effort by Republican governors of Medicaid expansion states to convince congressional Republicans that the Affordable Care Act's Medicaid expansion is worth keeping is unlikely to influence their drive to repeal the ACA and that coverage expansion, GOP experts say.
Instead, congressional Republicans are expected to push to convert Medicaid to a capped program of federal contributions to the states, which would give state officials much greater leeway to set eligibility and benefits, said Jon Gilmore, a Republican strategist in Arkansas. Critics say this type of block grant or per-capita grant approach would lead to states cutting people off Medicaid, reducing benefits and trimming payments to providers.
Governors have mixed views about this approach, since it could mean much less federal funding to their states over time. Congressional Democrats are expected to strongly oppose this type of Medicaid restructuring.
On Wednesday, Ohio Gov. John Kasich said expansion was key to battling opioid addiction in his state, where about 700,000 people have gained Medicaid coverage under the expansion.
“Thank God we expanded Medicaid because that Medicaid money is helping to rehab people,” Kasich said.
In addition, the Kasich administration recently released survey data showing that 75% of the people who gained Medicaid coverage were uninsured before becoming eligible for Medicaid. More than 1 in 4 have been diagnosed with at least one chronic condition, most commonly high blood pressure or high cholesterol, and 2% have been diagnosed with cancer.
“Access to Medicaid has facilitated access to care, reduced emergency department utilization, improved self-reported health, and supported employment and job-seeking,” a report by state officials concluded.
Since the November election, Republican Michigan Gov. Rick Snyder also has been outspoken about the benefits his state has seen from the ACA's Medicaid expansion. Snyder says he hopes his fellow Republicans recognize those benefits as they move to dismantle Obamacare. The expansion is projected to cover 620,000 Michiganders by 2020.
“I hope they carefully look at the success we've had in Michigan," Snyder told the Detroit News. “We're seeing a huge increase in coverage.”
More than 30,000 jobs and $2.3 billion in economic benefits accrued to Michigan since expansion, according to a new study by the University of Michigan's Institute for Healthcare Policy and Innovation posted Wednesday.
Also on Wednesday, Republican Arkansas Gov. Asa Hutchinson said he's asked members of President-elect Donald Trump's incoming administration to allow states to continue to receive enhanced federal funding for expansion. He also asked the Trump team to give states the freedom to set stricter eligibility standards and impose new employment requirements.
On the same day, North Carolina's new Democratic governor, Roy Cooper, announced he'll seek to expand Medicaid in his state, though the GOP-controlled Legislature likely will try to thwart that.
Despite these moves by governors in favor of Medicaid expansion, congressional Republicans seem determined to roll back the expansion, arguing it's unaffordable for both the federal government and the states. Under the ACA, the federal government this year will pay 95% of the cost of expanding Medicaid to adults with incomes up to 138% of the federal poverty level. That will phase down to 90% by 2020.
A proposal by Republican House Speaker Paul Ryan to repeal and replace the ACA would reduce the federal contribution for the expansion population to each state's standard federal matching rate, which would be closer to 60% on average. Some experts say many states would terminate their expansion programs if they had to come up with the billions of dollars to replace the lost federal funding.
Medicaid spending by the federal and state governments rose 13.9% to $532 billion in fiscal 2015, the first full year of implementation of coverage expansion, according to the Kaiser Family Foundation. The coverage expansion is estimated to have added about 12 million low-income adults to the Medicaid rolls in the 31 states that have implemented the law's expansion.
“It's not sustainable to continue the existing federal match no matter how much the governors getting it are liking it, regardless of their party,” said Brad Todd, a strategist and founding partner of On Message, a Republican media strategy firm.
The bipartisan think tank Committee for a Responsible Federal Budget has estimated that ending Medicaid expansion would save the government $1.1 trillion by 2027, though it would leave millions of Americans uninsured and increase hospitals' uncompensated-care costs.
“The results of the election show that there is some anger at the impact of Obamacare,” said Mark Weaver, a Republican strategist and founder of Communications Counsel, a consulting firm. “These voters will dictate more of what Congress will do than state legislators.”
As the Trump administration and congressional Republicans look for ways to give states more control over their Medicaid programs, conservative observers say they will draw on the experiences of states such as Arkansas, Indiana and Iowa, which have incorporated conservative, patient-responsibility features into their Medicaid expansion programs, said Kevin Madden, a Republican strategist at Hamilton Place Strategies.
Among Democrats, however, there is some optimism that efforts by governors such as Kasich and Snyder to highlight the benefits of Medicaid expansion could stall repeal efforts. Already, some Republican senators from expansion states, such as Shelly Moore Capito in West Virginia, have expressed reservations about rolling back the coverage extension.
“Votes could change when lawmakers hear from their constituents about the benefits they are losing,” said Robert Weiner, a Democratic strategist.