In the largest batch of gubernatorial contests since Republicans won big in 2010, this November has major implications for the future of Medicaid expansion in several states.
The potential changes are mostly isolated to races where there are good chances that the governor’s office could change parties. In some of those cases, state legislatures -- some of which bear the imprint of the 2010 GOP wave -- present obstacles to gubernatorial candidates pledging to expand Medicaid to more poor adults.
Of the 36 gubernatorial races this year, more than a dozen are in the 20 or so non-expansion states where the incumbent has either refused to expand Medicaid or tried and failed to do so -- and several of those races could go either way in the eyes of pollsters. In general, most Democrats favor Medicaid expansion while most Republicans are against it. Hanging in the balance in all of the elections is health coverage for hundreds of thousands of low-income people and millions in possible savings for states.
The state where the prospects for expansion could change the fastest after November is Maine, where Republican Gov. Paul LePage narrowly trails Mike Michaud, the Democratic congressman challenging the Tea Party favorite. What separates Maine from other states where the prospects for Medicaid expansion are up in the air is the legislature: Democratically controlled, it's already passed expansion five times and been rejected by LePage every time -- most recently in April. Democrats have a four-seat advantage in the state Senate, and some Maine Republicans have supported previous expansion bills.
“There’s no doubt [that] if Gov. LePage lost, Medicaid expansion would be supported by the next governor and it would very likely pass,” said Amy Fried, a University of Maine political scientist.
In Wisconsin, Democratic challenger Mary Burke will not have the advantage of an expansion-friendly legislature if she defeats incumbent Gov. Scott Walker, who narrowly leads a Real Clear Politics average of polls. But Jon Peacock, the research director for the pro-expansion Wisconsin Council on Family and Children, argues a change of leadership could create an opening even with a Republican-controlled legislature.
"If [Walker] is not back, it’s 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,’” he said. “I don’t know where to find $300 million worth of painless cuts. I think the politics of it really shifts.”
According to the state’s non-partisan legislative staff, if Wisconsin expands Medicaid by 2016, it would save upwards of $315 million over the next two-year budget period. The Medicaid expansion is entirely funded by the federal government through 2016, when support begins to gradually drop to 90 percent in 2020. Walker has steadfastly refused expansion while still increasing eligibility for childless adults within the existing Medicaid program on a limited basis. Burke could incorporate those savings into her budget proposal and press legislators to find cuts elsewhere if they insist on refusing expansion, Peacock said.
But even if the legislature doesn't support expanding Medicaid if Walker is voted out of office, Wisconsin governors can accept federal money without the legislature’s approval. That route, though, raises political, legal and practical challenges, according to analysts in the state. Burke's campaign wouldn't directly answer when asked whether she would pursue expansion on her own, saying only that she’ll “use every tool at her disposal to do so.”
But Florida’s Charlie Crist, the former Republican governor now running as a Democrat against Republican Gov. Rick Scott, has stated that he’d consider expanding Medicaid by executive order if he wins in November. The Republican-controlled legislature has so far refused to expand Medicaid. Scott, who won in 2010 by opposing the Affordable Care Act, later expressed support for Medicaid expansion -- a move that critics viewed as a half-hearted attempt to push the legislature.
As with Wisconsin, unilateral expansion would present challenges in Florida too. Crist would need additional state funding from the legislature to administer an expansion, according to Jay Wolfson, an expert on health law at the University of South Florida. Crist wouldn’t lose much support by unilaterally expanding from a Republican legislature that’s already angry over his defection, but the legislature would likely challenge the move, Wolfson said.
“By doing this, you are setting us [the state] up to create an obligation that is unfunded, and you don’t have the authority to do that,” he said. “I suspect this legislature in particular would challenge his executive authority to commit to a future expenditure.”
Polls have narrowly favored each candidate at various points in the campaign. The most recent survey, for instance, favored Scott by three points, while another just last week gave Crist a six-point lead.
What about expansion states?
For states that have already expanded Medicaid but face a change of leadership, the future is less certain. Arizona expanded Medicaid under Republican Gov. Jan Brewer, as did Arkansas under Democratic Gov. Mike Beebe. Republicans are favored in both gubernatorial races, and in both cases, the candidates have walked a fine line, neither calling for repeal nor offering support for expansion. Arizona’s Doug Ducey and Arkansas’ Asa Hutchinson have instead said they’ll closely monitor the program’s spending and its benefits.
That’s a sign that Medicaid expansion is shifting from a political no-go for Republican governors to a policy worth discussing, said David DiMartino, a national Democratic consultant. It’s much safer politically, he said, for Republicans to maintain an inherited policy than to anger a large voting bloc by taking away health care from low-income people.
“It’s political suicide to take that away from that population,” he said. “Anger is a very efficient organizing tool.”
That changing dynamic is perhaps most apparent in Republican-dominated Louisiana, where the campaign to replace Gov. Bobby Jindal is underway a year before the state’s gubernatorial primary. In contrast to Jindal, the two top Republican candidates, U.S. Sen. David Vitter and Lt. Gov Jay Dardenne, have both said they’re willing to explore Medicaid expansion in a state with the fifth highest uninsured rate and a safety-net hospital system that’s heavily dependent on a federal aid program scheduled to phase out.
In Louisiana -- where governors have traditionally exercised more power than most by initiating budget-writing, hand picking legislators for leadership and punishing opponents by rearranging priorities for capital projects -- a change at the top matters a whole lot, according to Preston Cross, the head of political science at the University of Louisiana, Lafayette.
“Frankly, there’s one branch of Louisiana government and the other two are subsidiaries,” he said.