Dylan Scott is a GOVERNING staff writer.E-mail: email@example.com
In many respects, despite being a federal law, the onus of implementing the Affordable Care Act (ACA) falls on the states: the Medicaid expansion, health insurance exchanges, dual-eligible demonstration projects, etc. The difference in action (or inaction) in states controlled by Democrats versus Republicans has been substantial since the law passed in 2010. Add the U.S. Supreme Court’s decision to make the ACA’s Medicaid expansion (the largest single provision in terms of meeting the goal of universal health insurance coverage) optional, and it seems possible that the outcome of the 2012 state elections could have as much of an impact on the law’s ultimate fate as whether Barack Obama or Mitt Romney reside in the White House for the next four years.
A month has passed since the Supreme Court largely upheld the law on June 28, and political contributions with at least a tangible connection to health-care reform are working their way into this year’s state races. While the numbers are not overwhelming, they offer an early indication of the role health care might have in November.
Eleven governor seats are up for grabs this fall, and winners will oversee much of their state's implementation of the ACA. To get a sense of the issue's impact, Governing analyzed campaign finance filings for two specific gubernatorial races: Indiana and North Carolina.
Keep in mind that state legislative elections will also have a significant impact: more than 6,000 seats are in play. An example: the Arkansas News Bureau reported last month that Democratic Gov. Mark Beebe's chances of expanding Medicaid would be severely hindered if Republicans can add to their majority in the state legislature in the November election. The Arkansas GOP has said it supports repealing the ACA in full.
A few other notes: Indiana was chosen because current Republican Gov. Mitch Daniels (who will be termed out at the end of this year) has explicitly said that his state’s decision about the Medicaid expansion would be left to the next governor, and the typically red state voted for Obama in 2008. North Carolina was picked because it has an outgoing Democratic governor, Bev Perdue, who supports the ACA, but many political observers (including Governing’s Louis Jacobson) believe it could swing to the GOP in November.
Many political analysts have indicated the Supreme Court decision specifically and health-care reform generally will impact the 2012 state elections. While the economy has consistently ranked as the most important issue for voters, a July 2012 Gallup poll found that 74 percent of Americans think making health care more affordable is "extremely or very important."
Some have portrayed the issue as an opening for Democrats in Republican-dominated states, particularly those where GOP leadership has expressed opposition to the now-voluntary Medicaid expansion. Indiana might fall under that umbrella. As Paul Starr, a Princeton professor of sociology and public affairs, wrote for The Democratic Strategist: “Democrats and progressive activists ought to regard it as a tremendous political opportunity to build support and voter turnout in states under Republican leadership… Democrats running for office should be able to make a forceful and persuasive case that carrying out health-care reform will be good for the state as a whole.”
Governing’s analysis stuck to contributions made since the Supreme Court ruling on June 28 and included the following kinds of contributors: those who listed their occupations as part of the health-care or medical fields; those lobbyists or lawyers involved with the health-care industry specifically; and political action committees that include health-care reform on their platform. Admittedly, that methodology is not perfect: only interviews with each and every individual or group, assuming they would be willing to disclose their reasons for donating, would clearly establish the intent of these contributions. It is also possible that others with less obvious connections have donated with the hopes of swaying health-care policy.
Regardless, given the ongoing conversation about the influence of campaign money on governance and the importance of health-care policymaking in the coming years, this analysis should give those interested a starting point for understanding the role that health care might play in 2012. Here’s what Governing found.
In North Carolina, Gov. Perdue has taken some steps to implement the ACA, including applying for health exchange establishment grants (the state has received more than $14 million) and signaling that the state will pursue a dual-eligible demonstration project. Perdue has elected not to seek a second term, which leaves her lieutenant governor, Walter Dalton, facing off against former Charlotte mayor Pat McCrory, the Republican nominee, for the governor’s office. McCrory said after the Supreme Court’s ruling that he would join other GOP governors, including Texas’s Rick Perry and Louisiana’s Bobby Jindal, in opposing the Medicaid expansion. Dalton has not taken a definitive position, although he has generally been supportive of the law. Opinion surveys show that Perdue is deeply unpopular in North Carolina, but tracking polls between Dalton and McCrory indicate that the race is fairly close.
According to Governing’s analysis, Dalton has received at least $17,200 post-Supreme Court from contributors with connections to health-care reform (out of $1.7 million for his entire candidacy), while McCrory has garnered $37,254 (out of $3.8 million). These are the early returns since the Court’s decision, and the number for both is likely higher: donations have only been disclosed through June 30. But there was some significant movement in the immediate aftermath of the ruling.
Based on the source of the contributions alone, Dalton and McCrory seem to be playing out the conventional wisdom: health-care providers (more likely to be hurt if a state opts out of the Medicaid expansion, for example) are donating to the Democrat. Numerous analysts have told Governing that providers, particularly hospitals, would likely push states to voluntarily expand Medicaid. At the same time, insurance companies (more likely to oppose aggressive implementation of the ACA’s reforms) appear to be funneling their money to the Republican. As National Journal reported in June, the main health insurance lobbying group spent more than $100 million to stop the law from passing in 2010.
Most notably, eight principals at AmWINS, an insurance firm based out of Charlotte, personally contributed a combined $18,000 to McCrory’s campaign in the three days following the Supreme Court’s decision. The company has published a number of "client advisories," available online, that express skepticism or trepidation about the ACA's impact on the insurance industry.
Both namesakes for the Griffin Estep Benefit Group, another health insurance provider, personally contributed $1,000 each to McCrory after the ruling. A Northwestern Mutual insurance agent and an attorney with McGuire Woods, a consulting firm with clients that include Blue Cross/Blue Shield, gave $1,000 and $2,000, respectively, to McCrory.
Dalton, on the other hand, saw money flowing in from supporters more likely to benefit from the kinds of health-care reform laid out in the ACA, particularly providers. John McNeil Jr., executive director of Liberty Healthcare Services, which provides skilled nursing and long-term care services, donated $4,000 to Dalton’s campaign the day after the Court’s ruling. C. Phillip Whitworth, a physician with Carolina Healthcare, also added $4,000, and Ann Goodnight, director of the SAS Institute, which operates a health-care center in Cary, N.C., handed Dalton $4,000 of her own.
Generally, health-care reform will likely play more of a background role than it did in 2010, when North Carolina Republicans used it as an attack point against Democrats, says Andrew Taylor, professor of political science at North Carolina State University. But he acknowledged that the Medicaid expansion and health insurance exchanges would be important topics during debates between McCrory and Dalton.
"I think those positions are going to be an important difference between the candidates. They also reinforce the partisan divide that already exists," Taylor says. "It's still a tremendous salient issue for Republicans, and I think they're going to use that."
In Indiana, Gov. Mitch Daniels said after the Supreme Court ruling that “any decision to expand Medicaid… is entirely the province of the next General Assembly and governor.” On August 2, he sought the input of the major gubernatorial candidates, including Republican Mike Pence and Democrat John Gregg, on the Medicaid expansion and the possibility of establishing a state health exchange. Pence has appeared opposed to expanding Medicaid and infamously compared the Supreme Court decision to 9/11, for which he was criticized and later apologized. Gregg has expressed openness to the idea, saying he wants to consult with voters before making a decision.
According to Governing’s analysis, Gregg has accumulated at least $50,000 in donations with connections to health-care reform since June 28 (out of $2.4 million for his entire candidacy), while Pence has received $17,660 (out of $4.8 million). As in North Carolina, donations for Indiana's candidates have only been disclosed through June 30. But again, there was some apparent action in the immediate wake of the Supreme Court decision.
Dave Becker, whose LinkedIn profile reveals that he is the CEO of First Internet Bank and a member of a group called Advancing Life Science & Health Care Information Technology, gave Gregg $20,000 on July 7. Lacy Johnson, an attorney who serves on the executive committee of HealthPAC, which seeks to influence Indiana’s health-care policymaking, personally contributed $5,000 to Gregg’s campaign the day after the Court’s ruling. The Victory 2012 PAC, which focuses on Indiana Democrats and includes access to quality health care on its platform, added another $26,000 in its donations to Gregg on June 30, bringing its total to $51,700.
Donations to Pence’s campaign were smaller (although he holds a substantial lead in overall fundraising), but there was still some notable action. Dane Miller, CEO of Biomet, a medical-device manufacturer, gave $10,000 to Pence on June 29. AstraZeneca, a biopharmaceutical company registered in Delaware, contributed $2,500 to the Republican nominee’s campaign the next day, as did McGuireWoods Consulting ($1,000), a lobbying firm with clients that include Blue Cross/Blue Shield. Several individuals who listed their occupation as “medical professional” also handed out smaller donations to Pence in the few days after the Court decision.
Some see Daniels’ call for input from the gubernatorial candidates on the Medicaid expansion as an opportunity for Pence, the presumed conservative favorite, to distinguish himself from Gregg, perceived as more liberal, on health-care reform, Andrew Downs, a political science professor at Indiana University, tells Governing. While health-care reform and the ACA specifically might not top the list of Indiana’s voters’ concerns, it will be a factor. The much-publicized U.S. Senate primary between Indiana State Treasurer Richard Mourdock and incumbent Sen. Richard Luger included commercials focused on the law, Downs says, and he expects some state legislative candidates to make it a talking point.
“It will and it won’t be an issue. Health-care reform is very complicated, so it’s hard for people to get invested in it,” Downs says. “But at the same time, it’s still an issue that people are cognizant of, and candidates might take that opportunity to talk about it.”
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Having a majority of seats in play in a year when many states have newly-drawn districts could greatly change the composition of statehouses. Will Republican state legislators be able to hold and extend their reach? Could Democrats regain some of the losses handed to them in 2010? Governing’s team of writers and contributors will monitor developments all the way up to Election Day and beyond.
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