The Fate of Medicaid Coverage for 2M People Could Hinge on the Outcomes of the Midterm Election

Oct. 29, 2014

Topics: Health Care Reform, Medicaid, Elections, 2014

**Updated Nov. 4, 2014**

The midterm election is today. Besides control of Congress, the election could determine whether more than two million uninsured residents gain or keep coverage under the Affordable Care Act's Medicaid expansion.

Races in the following states could determine how many more states join the 27 states that already have expanded Medicaid:

 

Click on the links above to go to a synopsis of the election and the stakes.

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Alaska

The Stakes: 26,000 could gain coverage with Medicaid expansion in 2016 (Source: Kaiser Family Foundation)

The Race: Incumbent Gov. Sean Parnell (R) vs. attorney Bill Walker (I)

The Current State Legislature:

  • +6 Republican advantage in state Senate
  • +12 Republican advantage in state House

The Details: Parnell opposes Medicaid expansion, calling it "overly costly" and saying it would put "an even greater burden on an already unsustainable system." However, Parnell has created a Medicaid Reform Advisory Reform Group, which is tasked in part with proposing solutions to address the coverage gap of a projected 17,290 state residents with incomes too high to qualify for non-expanded Medicaid but too low to quality for subsidies. Meanwhile, Walker says he "support[s] the Medicaid expansion with the caveat of continued Federal funding at its current level." Further, he has said Parnell's decision to oppose an expansion is "pure partisan politics that has caused people to not have health coverage."

The Post-Election Prospects: Walker, a former Republican, might be able to convince the state Legislature to take up some form of the expansion, at least for as long as the federal government is picking up 100% of the tab. Meanwhile, while Parnell almost surely would  not accept a formal Medicaid expansion with more federal dollars, the Medicaid Reform Advisory Group is scheduled to unveil its recommendations on Nov. 15, after the election. Parnell has been open to potential solutions to closing the coverage gap, which could result in some form of Medicaid expansion.

Arkansas

The Stakes: 143,000 could gain coverage with Medicaid expansion in 2016 (Source: KFF)

The Race: Former Rep. Mike Ross (D) vs. former U.S. Attorney Asa Hutchinson (R)

  • Rated Lean Republican By: Cook Political Report, Real Clear Politics
  • Rated Likely Republican By: Politico
  • FiveThirtyEight Forecast: 98% chance of Hutchinson win
  • Real Clear Politics Polling Average: Hutchinson +8.0%

The Current State Legislature:

  • +9 Republican advantage in state Senate, which approved an extension Arkansas' alternative "private option" Medicaid expansion this year by a vote of 27-8
  • +3 Republican advantage in state House, which also has one Green Party member and approved the extension this year by a vote of 76-24

The Details: Ross and Hutchinson are running to replace incumbent Gov. Mike Beebe (D), who helped enact Arkansas' alternative Medicaid expansion, in which nearly 205,000 state residents have enrolled as of Sept. 30. However, funding for the alternative expansion has to be reauthorized annually by a three-fourths majority of both the state House and Senate. The program was finally reauthorized in March after four failed votes in the state House. Ross says he "fully support[s]" the alternative expansion and would "work ... to protect [it]." Meanwhile, Hutchinson says he "view[s] the [alternative expansion] as a pilot project ... that can be ended if needed," adding that if it "is not accomplishing its objectives and it costs too much, then ... I will be the first one to call for its termination."

The Post-Election Prospects: As difficult a road as it might be to reauthorize funds for the state's alternative expansion, it might make it easier to get it done if a strong supporter like Ross is in office. Then again, having a Republican in seat who has taken a more cautious approach might give some Republicans more political cover if Hutchinson later encourages the Legislature to keep funding the program. While the outcome of the governor's race is important, various House races in the state might ultimately decide the fate of the alternative expansion.

Florida

The Stakes: 848,000 could gain coverage with Medicaid expansion in 2016 (Source: KFF)

The Race: Incumbent Gov. Rick Scott (R) vs. former Gov. Charlie Crist (D)

  • Rated Toss Up By: Cook Political Report, Real Clear Politics
  • Rated Lean Democratic By: Politico
  • FiveThirtyEight Forecast: 59% chance of Crist win
  • Real Clear Politics Polling Average: Crist +0.6%

The Current State Legislature:

  • +12 Republican advantage in state Senate
  • +28 Republican advantage in state House

The Details: Crist supports a full, conventional Medicaid expansion and has said he would consider calling a special session, expanding Medicaid by executive order or using budget vetoes to prod the GOP to support an expansion if he wins. Meanwhile, Scott previously has thrown his support behind using federal funds to help low-income individuals purchase private insurance via Florida's insurance exchange, but his plan was stymied by the Republican-controlled state House. According to the Tampa Tribune, "Scott has mostly ignored Medicaid expansion since" announcing his expansion plan.

The Post-Election Prospects: A Medicaid expansion is no guarantee no matter who wins the gubernatorial election. Crist has said that the outgoing state House speaker "was the main impediment" to an expansion, adding that he believes incoming Speaker Steve Crisafulli (R) "is less adamant than [the previous Speaker] has been on this issue" and could potentially support an expansion. However, Crisafulli has said that he has "not heard from a single Republican member or candidate who supports the Obamacare expansion of Medicaid" and told the News Service of Florida that he would not support expanding the program. Whether an election could change that position, or whether Crisafulli might yet support an alternative Medicaid expansion plan, remains to be seen.

Georgia

The Stakes: 478,000 could gain coverage with Medicaid expansion in 2016 (Source: KFF)

The Race: Incumbent Gov. Nathan Deal (R) vs. state Sen. Jason Carter (D)

  • Rated Toss Up By: Cook Political Report, Real Clear Politics
  • Rated Lean Republican By: Politico
  • FiveThirtyEight Forecast: 95% chance of Deal win
  • Real Clear Politics Polling Average: Deal +4.6%

The Current State Legislature:

  • +20 Republican advantage in state Senate
  • +59 Republican advantage in state House, which also has one Independent

The Details: Deal opposes Medicaid expansion, while challenger Jason Carter -- grandson of President Jimmy Carter (D) -- supports expanding the program.

The Post-Election Prospects: With Republicans firmly in control of the state Legislature, Carter likely would have trouble securing an expansion even if he pulls off the upset, particularly because lawmakers in the state have pre-emptively barred future governors from expanding Medicaid without approval from the Legislature. Carter has previously suggested than an alternative expansion similar to Arkansas' is a possibility, which could garner more support from state lawmakers. Regardless, Medicaid expansion in the state is expected to be an uphill battle.

Kansas

The Stakes: 100,000 could gain coverage with Medicaid expansion in 2016 (Source: KFF)

The Race: Incumbent Gov. Sam Brownback (R) vs. state Rep. Paul Davis (D)

  • Rated Toss Up By: Cook Political Report, Real Clear Politics
  • Rated Lean Democratic By: Politico
  • FiveThirtyEight Forecast: 80% chance of Davis win
  • Real Clear Politics Polling Average: Davis +2.0%

The Current State Legislature:

  • +24 Republican advantage in state Senate
  • +59 Republican advantage in state House

The Stakes: Brownback, who opposes Medicaid expansion, is facing a surprisingly strong challenge from Davis, who supports an expansion. Davis has said the state could possibly expand Medicaid by using federal funds to allow low-income residents to purchase coverage through the ACA's exchange. He also has argued that the state's "rural hospitals desperately need" the expansion.

The Post-Election Prospects: The state Legislature -- which already passed a law barring any future governor from expanding Medicaid without its approval -- is going to remain in Republican hands.

There's basically no chance Kansas will expand the program if Brownback is elected, but whether Davis could push through an expansion remains to be seen.

Maine

The Stakes: 28,000 could gain coverage with Medicaid expansion in 2016 (Source: KFF)

The Race: Incumbent Gov. Paul LePage (R) vs. Rep. Mike Michaud (D) and attorney Eliot Cutler (I)

  • Rated Toss Up By: Cook Political Report, Real Clear Politics
  • Rated Lean Democratic By: Politico
  • FiveThirtyEight Forecast: 56% chance of Michaud win
  • Real Clear Politics Polling Average: LePage +1.4%

The Current State Legislature:

  • +4 Democratic advantage in state Senate, which also has one Independent
  • +31 Democratic advantage in state House, which also has four "unenrolled" members

The Details: This is the most clear-cut of all the gubernatorial races. If Michaud wins, there will be a Medicaid expansion in Maine. Michaud has said that expanding the program "is the morally right thing to do" and is "literally an issue of life or death for some Mainers who are struggling without health care." Meanwhile, LePage has said a potential Medicaid expansion would be "sinful" and "ruinous" for Maine's budget and has vetoed five of the state Legislature's expansion bills.

Post-Election Prospects: If LePage wins, there won't be an expansion, unless expansion supporters can pick up enough seats in the Legislature to override a potential veto. Last time, supporters fell three votes shy in the State House of the necessary two-thirds majority to override.

Ohio

The Stakes: 446,000 could get coverage with Medicaid expansion in 2016 (Source: KFF)

The Gubernatorial Race: Incumbent Gov. John Kasich (R) vs. Cuyahoga County Executive Ed FitzGerald (D)

  • Rated Solid/Safe Republican By: Cook Political Report, Politico, Real Clear Politics
  • FiveThirtyEight Forecast: Greater than 99% chance of Kasich win
  • Real Clear Politics Polling Average: Kasich +20.7%

The Current State Legislature:

  • +13 Republicans in state Senate
  • +21 Republicans in state House

The Stakes: After the Ohio Legislature blocked Kasich's attempts to pass a Medicaid expansion through the Legislature, the governor convinced the Ohio Controlling Board to approve an expansion. Since then, more than 367,000 state residents have signed up under the expansion. However, the expansion funds run out after June 30, 2015, at the conclusion of the two-year budget cycle, leaving it up to the state Legislature to reauthorize the money.

The Post-Election Prospects: Heidi Gartland, University Hospitals' vice president of government relations, predicts "we won't know until the very, very end" whether the state Legislature will reauthorize the Medicaid expansion and that she doesn't "have a real strong sense" that majorities in either chamber support continuing expansion. Kasich has been a steadfast supporter of expansion but it is unclear if that will be enough to keep it going next year.

Wisconsin

The Stakes: 120,000 could gain coverage with Medicaid expansion in 2016 (Source: KFF)

The Race: Incumbent Gov. Scott Walker (R) vs. Madison School Board member and former Wisconsin Secretary of Commerce Mary Burke (D)

  • Rated Toss Up By: Cook Political Report, Real Clear Politics
  • Rated Lean Republican By: Politico
  • FiveThirtyEight Forecast: 75% chance of Walker win
  • Real Clear Politics Polling Average: Walker +2.2%

The Current State Legislature:

  • +3 Republican advantage in state Senate
  • +21 Republican advantage in state Assembly

The Details: Walker has partially expanded Medicaid, mostly using state funds, but opposes a complete Medicaid expansion. Burke, on the other hand, fully supports expanding Medicaid.

The Post-Election Prospects: The Wisconsin state Legislature likely will remain Republican-controlled, but governors under state law can accept federal money without the Legislature's approval, which would allow Burke to expand Medicaid if she wins. Wisconsin Council on Family and Children Research Director Jon Peacock also predicted that "[i]f (Walker) is not back, it [would be] a heck of a lot easier for Republicans in the Legislature to say, 'Well, as much [as] I have reservations about this, the Medicaid money, it's too good a deal.'"

Other State Legislature Races To Watch

There are a few other state legislative races in which the outcomes could affect Medicaid expansion. They are:

  • Indiana: Gov. Mike Pence (R) is discussing a potential Medicaid expansion with the federal government.
  • Utah: Gov. Gary Herbert (R) is discussing a potential Medicaid expansion with the federal government.
  • Virginia: Gov. Terry McAuliffe's (D) efforts to expand Medicaid largely have been blocked by the state Legislature.

by Joshua Zeitlin, staff writer
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