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A Separate Peace: GOP Governors And The Medicaid Expansion

A Separate Peace: GOP Governors And The Medicaid Expansion

By Tony Pugh, McClatchy Washington Bureau (TNS)

WASHINGTON — When Indiana Governor Mike Pence (R-IN) agreed to expand eligibility for his state’s Medicaid program, he made sure to call it “reform” rather than “expansion.”

The change reflects both the unique, conservative features of Indiana’s Medicaid plan as well as a complex political dynamic for Pence, a conservative Republican with rumored presidential aspirations.

By embracing a key pillar of the Affordable Care Act, Pence’s Medicaid plan could tarnish his conservative bona fides with large swaths of GOP voters and opinion makers.

So with party leaders in Washington calling for the repeal and replacement of Obamacare, Medicaid “reform” sounds and looks a lot better to GOP hardliners than the dreaded E-word.

“This has been a long process, but real reform takes work,” Pence said when the deal was done.

His careful wording is part of an awkward political dance that’s being performed nationwide as more Republican governors push for Medicaid expansion, despite tepid support from GOP state lawmakers and a continuing assault on the health care law by Republicans in Congress.

The governors’ efforts have muddied what had been one of their party’s clearest and strongest political messages — their universal disdain for the health care law.

“It’s always a mixed message when one group is doing something and the other’s not. There’s a political element behind all of this,” said Senator Richard Shelby (R-Ala).

But Republican strategist Keith Appell said the conflicting interests on the state and national levels haven’t created intra-party political tension.

“I haven’t seen anything that demonstrates that at all,” Appell said.

The health care law allows states to cover non-elderly adults earning up to 138 percent of the federal poverty level through Medicaid, the state-federal health plan for low-income Americans.

The federal government will pay all medical costs for the newly eligible enrollees through 2016 and no less than 90 percent of their costs thereafter.

To date, 28 states have implemented the Medicaid expansion. This includes 10 with Republican governors whose initial opposition gave way to pressure from voters, hospitals, and patient advocates to grab the federal Medicaid dollars and the new jobs that come with it.

In his recent State of the State speech, Republican North Carolina Governor Pat McCrory called on state lawmakers to join the expansion movement.

“Last session, we came close to passing Medicaid reform, but progress stalled on the one-yard line,” McCrory said. “Let’s run it up the middle and win a victory for families across North Carolina.”

By crafting an expansion that embodies conservative principles, Indiana’s Medicaid plan could become the template for other Republican governors wrestling with the politics of expansion.

It requires most Indiana Medicaid recipients to pay a small monthly premium for coverage that includes dental and vision benefits.

Those who earn below the poverty level won’t have to pay premiums. But if they don’t, they get no vision or dental benefits and must make co-payments toward their care.

Higher-earning enrollees who don’t pay their monthly premiums would lose their coverage in Indiana and couldn’t re-enroll for six months.

While the Obama administration rejected Indiana’s proposed work requirement for Medicaid enrollees, “they were willing to explore some of these more experimental provisions, to see what works and to compromise with these governors that want these folks to have more skin in the game,” said Caroline Pearson, vice president with Avalere Health, a Washington consulting firm.

Any North Carolina expansion plan would likewise “require personal and financial responsibility from those who would be covered,” McCrory said.

Appell said Indiana’s plan is “perhaps the best approach you can take as a conservative.”

“It’s a gutsy call on his part,” Appell said of Pence, “because he also gets some flack.”

Nina Owcharenko, director of the Center for Health Policy Studies at the Heritage Foundation, a conservative Washington think tank, said Indiana’s Medicaid deal takes one step forward by incorporating a number of personal responsibility provisions, “but two steps backwards” by expanding a broken program to new enrollees.

“It doesn’t make sense to me that to reform a program you expand it,” Owcharenko said. “Why would you add more people to something and then say, ‘And now we’re going to figure out how to fix it?’ The boat has a hole in it. It’s sinking, but let’s add more people so it sinks faster?”

Republican Governors Bill Haslam of Tennessee (R-TN), Gary Herbert of Utah (R-UT), and Matt Mead of Wyoming (R-WY) also have called for new Medicaid enrollees to pay premiums. But Haslam’s and Mead’s expansion proposals died earlier this month amid resistance from Republican state lawmakers.

Lobbying by Americans for Prosperity, an influential conservative political advocacy group funded by the billionaire Koch brothers, helped kill Haslam’s proposal in Tennessee. The group opposes the Affordable Care Act.

“Governor (Bill) Haslam was trying to create an independent version of Medicaid expansion, and so far he hasn’t been able to persuade the legislature to do it,” said Senator Lamar Alexander (R-TN).

In Utah, Herbert’s Medicaid plan cleared a state Senate committee vote this week and will soon be debated by the full Senate.

Photo: Medill DC via Flickr

Republicans Hold The Line Against Medicaid Expansion

Republicans Hold The Line Against Medicaid Expansion

By Mark Z. Barabak and Noam N. Levey, Tribune Washington Bureau (TNS)

WASHINGTON –– As President Barack Obama fights in Congress and the courts to preserve the Affordable Care Act, the health care law faces still another threat: Republicans in statehouses, many bucking governors of their own party eager to accept its flow of federal money.

When a group of Republican governors sued to overturn Obama’s signature achievement, Wyoming’s Matt Mead was among them, arguing that the law was a vast overreach that violated the Constitution and trampled the right of states to set their own policies.

But after the U.S. Supreme Court rejected that argument, Mead decided it would be foolhardy to pass up tens of millions of dollars the act provided to expand coverage for Wyoming’s uninsured adults.

“We have fought the fight,” Mead said last month in his State of the State address. “We’ve done our best to find a fit for Wyoming. We are out of timeouts, and we need to address Medicaid expansion.”

That argument failed to persuade lawmakers in Wyoming’s Republican-run Senate, which voted 19 to 11 to reject Mead’s proposal. Many of the opponents, said Phil Nicholas, the Senate president, had campaigned on a promise to block Medicaid expansion.

A similar dynamic is playing out in legislatures across the country, including Arizona, Florida, and Utah, where conservative lawmakers remain a formidable hurdle to momentum building behind the Democratic goal of guaranteed health care coverage.

They have proved far more effective at thwarting the 2010 health care law than their Republican counterparts in Washington, who have voted more than 50 times to repeal all or part of the program, largely to no avail.

This month, in Tennessee’s Republican-led Senate, a committee rejected a proposal to extend Medicaid coverage despite a strong push by the state’s Republican governor, Bill Haslam, and waivers from the Obama administration meant to allay conservative concerns.

“I said from the very beginning it would be difficult,” Haslam said after his plan was shot down. “I think what you saw today is a measure of just how difficult.”

The role of state lawmakers could become even more important depending how the Supreme Court rules this spring in another challenge to the health care law. Opponents are seeking to end the public subsidy for residents in as many as 37 states where the federal government operates the marketplace for health insurance.

To restore the subsidies, which are seen as vital to making coverage affordable, legislatures in many states would likely have to vote to run the marketplaces on their own, as just 13 states do now.

Throwing the issue into the hands of state legislators could pose a serious threat to the future of the health care law as Republican strength — bolstered by 2014’s conservative wave — has reached a high-water mark.

The GOP gained more than 300 legislative seats nationwide as part of its November landslide, taking control of 30 statehouses and well over half the nation’s 7,383 legislative seats. That is the most Republicans have held since 1920 and the most legislative chambers it has controlled since Reconstruction.

Although the health care law was not an issue in every legislative contest, opposition to the president and his agenda was an overriding theme for many Republican candidates, said Tim Storey, a political analyst at the nonpartisan National Conference of State Legislatures.

“Many of the rank-and-file Republicans are extraordinarily skeptical of anything that’s connected to this administration,” Storey said, and have “a hard-wired reluctance to consider anything related to Obamacare and Medicaid expansion.”

Twenty-eight states and the District of Columbia have elected to accept federal aid to expand their Medicaid programs and provide health care coverage to low-income residents, a key goal of the Affordable Care Act. Thirteen of those states have Republican governors.

The law provides federal funding to pay for the expansion, though the aid is gradually phased down so that states will ultimately pay 10 percent of the cost — a prospect many local lawmakers find worrisome.

“For me, there are three issues: affordability, sustainability and uncertainty,” said Jim Dunnigan, majority leader of the Republican-run House in Utah, where GOP Gov. Gary Herbert is pushing to expand Medicaid. “The other thing is the case before the Supreme Court. … That’s another big piece of uncertainty.”

Obama administration officials and other supporters of the Affordable Care Act hoped the generous aid from Washington would persuade more states to back Medicaid expansion. Across the country, hospitals, physician groups and chambers of commerce have heavily lobbied governors and state lawmakers to accept the federal money, arguing the additional health care coverage would lighten the burden on providers who deliver millions of dollars’ worth of free care to uninsured patients each year.

That helped convince Republican governors in several states, including Arizona, Arkansas, Iowa, Nevada, Michigan, and Ohio. (A group of conservative Arizona legislators is suing to roll back the state’s Medicaid expansion.)

There has been vigorous pushback elsewhere as well. A lobbying blitz led by Americans for Prosperity, the conservative group funded by the billionaire Koch brothers, was instrumental in derailing the proposed Medicaid expansion in Tennessee, and their hope is to replicate that success across the country.

“Our opportunities for success and for good free-market prescriptions, especially around healthcare, government spending and energy, are out there in the states,” said Luke Hilgemann, the group’s chief executive, who said stopping the Affordable Care Act was a top priority of voters the group canvassed in last year’s midterm election.

To expand coverage, the administration has signaled a new willingness to give Republican governors more flexibility to adjust their Medicaid programs, including charging premiums and co-payments, a longtime demand of conservatives who argue such cost-sharing promotes greater personal responsibility.

The deal that Indiana Gov. Mike Pence, a staunch conservative, struck with the Obama administration last month to expand Medicaid buoyed supporters’ hopes that other Republican-led states would soon follow, including Tennessee and Wyoming.

But in an interview, Mead, Wyoming’s governor, sounded less than optimistic after the Senate there rejected his plan, which seeks to expand coverage to more than 17,000 of the state’s uninsured.

“I wouldn’t say it’s dead,” Mead said. “But certainly with what happened … it’s even more of an uphill challenge.”

Photo: USFWS Mountain Prairie via Flickr