Same story, different week: A governor who opposed the Affordable Care Act changes course and announces plans to opt into the Medicaid expansion.
Supporters of the ACA rejoice, conservatives grumble, and a new number gets tacked on the board — 24 states opting in, at last count.
Yet there’s more to the story than governors’ speeches. In at least eight of those states, lawmakers are warning that they may not go along with expansion plans.
Those legislative logjams — and what governors need to do to circumvent them — vary state by state , but the fights are falling out along party lines.
In Missouri, two GOP-led House committees this week voted down Medicaid expansion plans, despite Democrat Gov. Jay Nixon’s pledge to opt into the measure last year. Republican lawmakers in Arkansas, Montana and Washington have similarly been skeptical of their Democratic governors’ expansion positions. Meanwhile, four GOP governors who have backed the expansion are having difficulty corralling members of their own party.
“All the states are different,” Matt Salo, executive director of the National Association of Medicaid Directors, told me. “But for all intents and purposes, you need the executive and legislative branches to agree.”
GOP Legislatures Balk Over Cost, Risk
That basic civics lesson has been largely ignored as one governor after another announced plans to participate in the law’s Medicaid expansion.
Proponents of the ACA have been particularly gleeful as several leading Republican governors — Arizona’s Jan Brewer, Ohio’s John Kasich, Michigan’s Rick Snyder and Florida’s Rick Scott — have come out in favor of the expansion across the past six weeks.
“The fact that [those Republican] governors have opted into the Medicaid expansion are game-changers,” Ron Pollack of Families USA told me last week, after Scott’s announcement.
“I think the dominoes are going to fall into place fairly soon.”
Pollack’s probably right. Scott’s decision was especially significant, both for its practical — Florida stands to insure one million more residents through the expansion — and symbolic implications, given his status as a leading critic of Obamacare. And last week’s announcement may well have given New Jersey’s Chris Christie more cover on Tuesday to announce his own support for the Medicaid expansion.
But even if the game’s changed for Republican governors, many GOP legislators within their own states continue to fight the Medicaid expansion using a well-worn playbook to criticize the law’s costs and possible risks.
Arizona’s House speaker: “We have no faith in the federal government” to fulfill its Medicaid obligations.
Florida’s House speaker: “I am personally skeptical that this inflexible law will improve the quality of health care in our state and ensure our long-term financial stability.”
Michigan’s House speaker’s spokesperson: “The federal government has a history of working with states to start long-term programs while providing short-term funding, and then sticking state taxpayers with the future financial liability.”
Ohio’s House speaker: “Our problem … [is] if the federal government continues to operate the way it has the last several years, they may or may not have the money to live up to their obligations.”
What Comes Next if There’s a Split
Some state lawmakers appear unclear on what happens if the Legislature and governor differ on the Medicaid expansion.
“It would be a very legally interesting situation,” Brian Kane, Idaho’s deputy attorney general, testified at a committee hearing last summer. “That’s a very involved powers-of-government question, from my perspective.”
But what it boils down to: The governors who favor the Medicaid expansion really can’t move forward without their legislatures, which need to authorize and appropriate the necessary funds.
(Governors who want to expand Medicaid can make provisional arrangements to avoid last-minute scrambling, according to Salo. For example, they can work with vendors to have systems that are ready to operate under the expansion’s expanded eligibility requirements if necessary, should the state move to opt in after all.)
Under the Supreme Court’s ruling on the ACA, legislators can wait months or years to hammer out an agreement, if they want to opt in at all. But there’s a significant financial incentive to reach a decision before the year’s done.
The federal government’s 100% matching funds are only available from Jan. 1, 2014 through Dec. 31, 2016, Salo noted. “And every month that you’re not [part of the expansion] is a month that you’re not getting that Medicaid match.”
Legislatures May Be Playing Role of Token Resistance
That financial hook, which has swayed staunch conservatives like Scott and Christie, may ultimately end up winning over legislatures too.
(And if it seems like we’ve been here before — well, we have. After considerable hue and cry, every state governor ended up accepting stimulus funds because the package was seen as just too good.)
The government also continues to sweeten the pot for holdouts; Arkansas Gov. Mike Beebe on Tuesday announced that HHS had approved an unusual waiver to allow the state to use federal funds to help residents buy private insurance.
Meanwhile, it’s possible that the most critical legislatures may simply be going through the motions of offering token, partisan resistance. Earlier this week, the GOP chair of North Dakota’s House health committee warned the Associated Press that “the caucus [was] divided” on its upcoming vote over Medicaid expansion.
A day later, that divided caucus voted 12-1 to opt into the expansion.