Close governor races could decide future of Medicaid

Georgia Democratic gubernatorial nominee Stacey Abrams, whose family was uninsured when she was growing up, says she's running to “expand Medicaid and keep hospital doors open.”

Accepting the Affordable Care Act expansion would bring in $3 billion in federal funding a year and cover nearly 500,000 Georgians.

She's one of several Democratic gubernatorial candidates making a similar pitch in states that have not extended Medicaid to low-income adults as allowed by the ACA. Others are Andrew Gillum in Florida, Laura Kelly in Kansas, and Janet Mills in Maine. All are locked in tight races against Republicans who strongly oppose expansion.

The future of Medicaid has a lot riding on the November elections. Voters in eight states that haven't expanded Medicaid will choose a new governor for an open seat, with pollsters giving Democrats favoring expansion a solid chance of scoring pickups. Democrats also are expected to gain seats in a number of state legislatures, making expansion more likely in states like North Carolina where the governor wants it.

Advocates see election successes this November as a springboard to expanding Medicaid in nearly all 50 states. And the single-biggest factor in winning expansion in balky states like Alaska, Louisiana and Virginia, they say, has been the election of a governor who supports it.

“These state elections profoundly matter for Medicaid's future,” said Elliot Fishman, senior director of health policy for Families USA, a pro-expansion advocacy group. “They will shape the basic structure of Medicaid in both expansion and non-expansion states.”

Medicaid expansion opponents also see the elections as critical. They argue that Democrats are hurting their states by pushing for expansion, which they say neither the states nor the federal government can afford.

“In every state that expanded Medicaid, we have seen an unsustainable burden put on the backs of taxpayers and the crowding out of resources for people who are truly in need,” said David Barnes, policy manager for Americans for Prosperity, a conservative group that has lobbied states against Medicaid expansion.

Hospitals and other provider groups are supporting efforts to expand Medicaid, though they are keeping a low political profile in the election campaigns. They say expansion is critical to reducing uncompensated care and helping hospitals in rural and low-income areas survive. By not expanding Medicaid, “We're losing out on billions of federal healthcare dollars, with an impact on our economy, our workforce and ensuring access to care,” said Ethan James, executive vice president of external affairs for the Georgia Hospital Association.

In several states, Democratic and Republican gubernatorial candidates are facing off over whether and how to keep their state's expansion. Republicans such as Bill Schuette in Michigan and Mike DeWine in Ohio have flipped their prior positions and say they now support keeping expansion—but only with work requirements for non-disabled beneficiaries. Their respective Democratic opponents, Gretchen Whitmer and Richard Cordray, are strong expansion supporters who oppose work requirements.

In Alaska, Republican Mike Dunleavy, running against Gov. Bill Walker, an independent, and Democrat Mark Begich—both of whom favor keeping the state's Medicaid expansion in place—says he would review the program to find ways to reduce costs.

ALASKA: expansion state

WHO: Gov. Bill Walker, Independent, favors keeping expansion

WHO: Mike Dunleavy, Republican, critical of expansion's costs, favors reviewing expansion program

WHO: Mark Begich, Democrat, favors keeping expansion

Estimated number of expansion enrollees: 40,000

Poll: Leaning toward Walker

And in three states whose Republican-led legislatures have repeatedly rebuffed expansion—Idaho, Nebraska and Utah—voters will decide in binding ballot initiatives whether to extend Medicaid coverage to adults with incomes below 138% of the federal poverty level.

Supporters of the three ballot initiatives hope voters will follow the example of Maine voters, who overwhelmingly approved a binding expansion initiative last year. But they hope to avoid the impasse in Maine, where Republican Gov. Paul LePage has refused to implement the expansion. Democratic gubernatorial candidate Mills has promised to enact it, while Republican Shawn Moody has vowed to block it.

MAINE: hasn't expanded Medicaid

WHO: Janet Mills, Democrat, favors expansion

WHO: Shawn Moody, Republican, opposes expansion

WHO: Terry Hayes, Independent, favors expansion

WHO: Alan Caron, Independent, favors expansion

Estimated number of expansion enrollees: 70,000

Poll: Leaning toward Mills

(Maine voters approved expansion, but current Republican governor has blocked it.)

In Idaho, both the Republican and Democratic gubernatorial candidates say they will honor the voters' choice on the ballot initiative. GOP state officials in Utah are expected to do the same. The situation is more uncertain in Nebraska, where Republican Gov. Pete Ricketts has fervently opposed expansion.

Polls show the public supports Medicaid expansion, including in red states. A July tracking poll by the Kaiser Family Foundation found that in the 14 states that have not expanded Medicaid, 51% of those polled said they favor expansion, with 39% opposing it. A recent UtahPolicy.com poll found 65% of Utahans support the ballot initiative to expand, with 30% opposing it.

So rather than campaigning against expansion directly, some GOP gubernatorial candidates like Schuette and DeWine instead have promised to establish work requirements that would limit enrollment. “I think we'll see not outright opposition to expansion but more efforts to put up barriers when an expansion program is enacted,” said Adam Searing, an associate professor of public policy at Georgetown University.

Meanwhile, the future of congressional GOP efforts to repeal the ACA and Medicaid expansion and restructure traditional Medicaid is also at stake in November. Democrats are favored to win control of the House, with an outside chance of taking the Senate as well. If they win either or both chambers, those GOP plans would be blocked.

Here's how the Medicaid fight is playing out in the governor's races in several key states.

Tallahassee Mayor Andrew Gillum, a progressive who scored an upset win in the Democratic primary, also has placed Medicaid expansion at the heart of his campaign. It would cover an estimated 700,000 Floridians. “I will fight for Medicaid expansion, Medicare for all and essential protections for women's healthcare and pre-existing conditions,” he recently said. Ron DeSantis, his Republican opponent, is adamantly against expansion, having voted many times in Congress to repeal the ACA.

The prospects for legislative approval of expansion if Gillum wins are iffy. Democrats are expected to gain seats but fall short of winning control of either chamber. “If a Democratic governor makes it a condition of passing a budget or another legislative priority, it would be easier to find a way to get to yes,” said Gregory Koger, a University of Miami political science professor.

FLORIDA: hasn't expanded Medicaid

WHO: Andrew Gillum, Democrat, favors expansion

WHO: Ron DeSantis, Republican, opposes expansion

Estimated number of expansion enrollees: 700,000

Poll: Toss-up

Stacey Abrams, former Statehouse minority leader, has made Medicaid expansion the marquee issue of her campaign. She argues it would reduce high maternal and infant mortality rates, drive down uncompensated care, and save rural hospitals in a state where seven have closed since 2013.

Republican Brian Kemp rejects expansion, saying Medicaid costs too much and doesn't work. He favors a “free-market solution that enhances healthcare coverage and reduces cost.”

The Georgia Hospital Association has pushed for a more limited, conservative-friendly Medicaid expansion to cover the poorest Georgians and help struggling rural hospitals.

Even if Abrams wins and Democrats gain some seats in the GOP-controlled Legislature, she would face a tough challenge persuading lawmakers to expand Medicaid.

GEORGIA: hasn't expanded Medicaid

WHO: Stacey Abrams, Democrat, favors expansion

WHO: Brian Kemp, Republican, opposes expansion

Estimated number of expansion enrollees: 500,000

Poll: Toss-up

Democratic gubernatorial candidate Laura Kelly is promising to cover 150,000 Kansans by passing Medicaid expansion in her first year in office. She says it's critical for keeping rural hospitals and clinics open.

Analysts say passing expansion is plausible in this deep-red state where the GOP-controlled Legislature passed expansion last year but narrowly failed to override Republican Gov. Sam Brownback's veto. Kris Kobach, Kelly's Republican opponent, opposes expansion.

Republican State Rep. Susan Concannon, an expansion supporter, is cautiously optimistic that if Kelly wins, she could get a new expansion bill through the Legislature. “If we have a governor who would sign the bill, I would find a way to get it to the floor,” she said. “It would be a difficult vote for some conservatives in rural areas because their communities want it, but politically they don't want to vote for it.”

It might help if voters in neighboring Nebraska approve the ballot initiative to expand Medicaid to an estimated 90,000 people. “If it's right next door, it's right in front of our face, and that would make a difference,” Concannon said.

KANSAS: hasn't expanded Medicaid

WHO: Laura Kelly, Democrat, favors expansion

WHO: Kris Kobach, Republican, opposes expansion

WHO: Greg Orman, Independent, favors expansion

Estimated number of expansion enrollees: 150,000

Poll: Toss-up between Kelly and Kobach

In Michigan, Democratic gubernatorial candidate Whitmer and Republican Schuette disagree on whether to proceed with the state's waiver request to add a work requirement to its Medicaid expansion program covering about 650,000 people.

Legislative analysts predict the work requirement would cause 5% to 10% of beneficiaries to drop out of coverage.

MICHIGAN: expansion state

WHO: Gretchen Whitmer, Democrat, favors keeping expansion without work requirement

WHO: Bill Schuette, Republican, favors keeping expansion with work requirement

Estimated number of expansion enrollees: 650,000

Poll: Whitmer is the front-runner

The same disagreement over a work requirement is playing out in Ohio between Democrat Cordray and Republican DeWine, who are neck and neck in the polls.

OHIO: expansion state

WHO: Richard Cordray, Democrat, favors keeping expansion

WHO: Mike DeWine, Republican, favors keeping expansion with work requirement

Estimated number of expansion enrollees: 700,000

Poll: Toss-up

Whitmer, who helped pass Michigan's expansion, warns that the real goal of the work requirement is to take coverage away from people, and that could be “devastating.” Schuette, who's trailing in the polls, said it would encourage people to get a job and leave more resources for people who need help more.

Chris Mitchell, senior vice president of advocacy for the Michigan Hospital Association, which strongly supports the expansion, said it's unlikely that a Whitmer victory would derail the waiver. It was mandated by the GOP-controlled Legislature and backed by Republican Gov. Rick Snyder.

The state hospital association expects the work requirement to be approved by the CMS before year-end. It would take a major effort by the next Legislature and governor to significantly change that, Mitchell said. He noted, however, that lawsuits challenging CMS approval of the work requirement waivers in Kentucky and Arkansas are a wild card.

Fishman of Families USA said the work requirement is just one of many key issues about the future of Medicaid in both expansion and non-expansion states that will be shaped by the November elections. Voters will decide whether the ACA's Medicaid expansions will move forward or be rolled back.

“There is a huge swing in terms of the outcome of this election, from securing existing levels of coverage to significantly damaging them,” he said.

Note: Estimates on the number of expansion enrollees can vary based on a number of variables, including which databases were used, when the data was tabulated, and assumptions made on eligibility. The polling analysis is from Real Clear Politics.