Up to 2.7 million people across nine states could soon get added to Medicaid rolls depending on next week's midterm elections, according to a new analysis.
Healthcare consulting firm Avalere's predictions showcase the increasingly bullish national outlook for Medicaid expansion. But those programs could look very different state by state, even where Democratic candidates with a close shot at winning are running on expansion. Some providers say the result could stray from the Affordable Care Act model.
"I go back to every state is different: If you've seen one Medicaid program, you've seen one Medicaid program," said Ethan James of the Georgia Hospital Association. "Same with an expansion: Every state would do it differently."
In Georgia, providers have been working on three different expansion options with stakeholders through a state Medicaid waiver proposal that hasn't been approved. Two of these options expand coverage up to 100% of the federal poverty level, and one up to the ACA's level of 138%. The state has the third-highest uninsured rate of poor adults, according to Kaiser Family Foundation data.
Stacey Abrams, the state's Democratic candidate for governor, has made Medicaid expansion part of her platform. But practically, she would need buy-in from the GOP-held state Senate and House of Representatives. In 2014, the General Assembly passed a bill to block a governor from unilaterally expanding Medicaid without state lawmakers' support.
Georgia, along with Florida, would count for the biggest boost in Medicaid numbers if they expand the program. Alone, these two states account for 28% of all U.S. adults who fall into the coverage gap by not qualifying for either their state's Medicaid program or for individual market subsidies. They have the second- and third-highest number of uninsured, behind Texas. Southern states together account for 89% of people in the coverage gap.
But mention of Medicaid expansion is still politically toxic for many, James said.
"The term 'expansion' can be radioactive. You say 'Medicaid expansion' and you immediately get policymakers flinching."
He noted that the hospital industry, when talking about extending coverage, refers to "access to care" instead.
All six of the toss-up gubernatorial races listed in Avalere's analysis would have to go to pro-expansion Democrats. Even if they do, a majority of state lawmakers in legislatures that are currently held by GOP majorities and super majorities would have to be amenable.
Different scenarios for this contingency have played out in North Carolina and Virginia. Gov. Roy Cooper (D-N.C.) pushed for expansion after he won his seat in 2017, but the legislature blocked his efforts. Gov. Ralph Northam (D-Va.), after months of work, was able to secure support from both chambers of his legislature where Republicans hold only slim majorities. But he has acknowledged the GOP state lawmakers' battering at the polls in 2017 likely influenced the outcome.
Avalere also includes potential enrollment numbers from the more-certain outcomes of voter ballot initiatives to expand Medicaid in Nebraska, Utah and Idaho. Expansion advocates in those states are optimistic these measures will pass.
For governors' races, the analysts focused on Florida, Georgia, Kansas, Maine, South Dakota and Wisconsin, where polling shows a dead heat between Republican and Democratic candidates. They did not include Oklahoma, where Democratic candidate Drew Edmondson is running on Medicaid expansion and is now polling neck-and-neck with the GOP candidate Kevin Stitt.
The Midwest has a much smaller share of people who could qualify for expansion, accounting for just 7% of the coverage gap nationwide, according to Kaiser. Accordingly, some Midwestern providers—in Nebraska, for instance—have tempered expectations for how much expanded Medicaid coverage would boost their margins.
Avalere's estimates—that 2.7 million adults in nine states could be eligible should Medicaid be expanded there—are higher than the Kaiser Family Foundation's estimate of 2.2 million poor adults nationwide who fall in the coverage gap.
Medicaid expansion has become increasingly accepted in purple and red states, as evidenced Tuesday when Idaho's outgoing Gov. "Butch" Otter publicly endorsed it in an ad for the state's ballot measure—bucking opposition from conservatives and dubbing it a "home-grown solution."
But as James noted, conservatives still question the costs. He said he is aware of those costs.
"We don't want something that is going to bankrupt the state," he said. "If the state can't afford the costs of an expansion, then they will start cutting other programs, which won't help anyone."
With the Trump administration, there is also push-pull between the federal government—which funds the lion's share of coverage—and the states' tight healthcare budgets.
CMS Administrator Seema Verma has criticized the incentives posed when states receive far more dollars for covering so-called "able-bodied" adults than the much poorer and sicker traditional Medicaid recipients.
Over the summer, she told a Senate oversight panel that some states are finding ways to shift higher-cost traditional Medicaid recipients to the expansion program in order to save money. If a state's eligibility standards for disabled people varies from the federal standard, they may move some of those beneficiaries to the expansion rolls to save money. Nebraska's health department proposed this as one idea to cut state costs in order to fund expansion.
This fight has been especially fraught in Maine, where outgoing Gov. Paul LePage has blocked implementation of the voter-approved ballot measure to expand and lost an appeal to a lawsuit filed to force him to start rolling out the program.
The election to replace him epitomizes the battle. Republican candidate Shawn Moody has echoed LePage's position that the state needs to find a way to pay for its share of the funding before the program takes effect.
The Democrat is Maine's attorney general, Janet Mills, who backed the lawsuit against LePage.
