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Elections Put Medicaid Expansion at Risk in Some States

With the increase of Republican governors and legislative chambers after midterms, some states that have already expanded Medicaid now face the possibility of repeal.

With the re-election of governors who remain obstinate to Medicaid expansion in Wisconsin and elsewhere, it doesn’t look like the issue will shift dramatically toward greater expansion. But with legislative shakeups and some new governors, could Medicaid expansion get repealed in states that already approved it under previous leadership?

In most states where Republicans -- who are typically less supportive of Medicaid expansion -- claimed the governorship or a state legislative chamber repeal is highly unlikely because proponents still have enough control to block it. But in several states there will be fierce debate over whether to continue the expansion, which could end health coverage for hundreds of thousands of low-income people. 

The possibility of repeal is strongest In Arkansas, the first state to establish a privatized version of Medicaid expansion that could appeal to other conservative states. Gov. Mike Beebe, a Democrat, passed the so-called private option with a Republican-controlled legislature, but Beebe faced term limits in the 2014 election. Asa Hutchinson, the Republican who won the gubernatorial race Tuesday, has neither condemned the expansion nor offered his support, saying only that he wants to closely monitor its costs going forward. 

It’s the legislature that presents the bigger hurdle. The Arkansas constitution requires the approval of three-quarters of legislators for most spending, making yearly reauthorization a challenge on such a contentious issue. The 2014 reauthorization took five attempts in the House and passed both chambers very narrowly. Republicans expanded their House majority to 64 seats from 51 and to 24 from 21 in the 30-member Senate after Tuesday’s election. 

Some of those members actively campaigned against the privatized Medicaid expansion. Rep. Ken Bragg, the House majority leader, said in an interview that the expansion wouldn’t pass if he held a vote today. “Right now, if you took a vote based on what everybody ran on, the votes aren’t there,” he said.

Proponents are already gathering data to present to new lawmakers when the legislature convenes in January, and they’re willing to make changes, though they’re not sure at this point what those changes will be, Bragg said. “A lot of them haven’t sat through the hours and hours of testimony that we did,” he said. “A lot of them just saw it from a high level and philosophically opposed it.”

Another state where Medicaid expansion will come up for a vote again is Ohio, where Republican Gov. John Kasich cruised to re-election a year after bypassing the GOP-controlled legislature to push the expansion through. But the authority for that expansion runs out after the budget cycle ending in June, meaning Kasich needs the support of his legislature to include the expansion in the next budget. That legislature is now more Republican than it has ever been after Tuesday’s election. 

It’s unclear what the legislature will do, especially with a shift in leadership in the House, with both the speaker and speaker pro tempore leaving. But outgoing Speaker Pro tempore Matt Huffman, who faces term limits, said it’s unlikely the legislature will automatically continue a traditional Medicaid expansion. It’s more likely members will seek changes to rein in costs or other reforms to doctor reimbursement and patient cost-sharing, he said.  “Is it simply going to be Gov. Kasich says, ‘This is what we should do,’ and everyone says OK? Probably not,” Huffman said. “Hopefully there will be a more in-depth discussion than there was the last time. There wasn’t the give-and-take of a legislative process.”

Those may be changes Kasich would welcome. He’s staked a position as a reformer after shifting away from the powerful nursing-home lobby to community-based care, among other things. But he wasn’t able to put a more conservative spin on Medicaid expansion when he bypassed the legislature. In his favor is an overwhelming re-election victory, in which he even won the Democratic opponent's home county of Cuyahoga, the party's biggest stronghold, said John Green, a University of Akron political scientist. On top of that, the incoming speaker, Cliff Rosenberger, is pragmatic and likely willing to strike a deal, Green said.

"The bad news is the Republicans have a larger majority in the lower house, where the problem was to begin with, and they’re more conservative, so the governor may well consider a different strategy," Green said. "He may have to negotiate with the state legislature." 

Two other Medicaid expansion states facing major political changes are West Virginia, where Republicans seized control of the statehouse for the first time in 86 years and knotted up the Senate, and Arizona, which has a new Republican governor to replace Republican Jan Brewer, who pushed expansion through without majority support of her own party. 

But in the case of West Virginia, Democrat Earl Ray Tomblin would stand in the way of any repeal, and it’s a non-starter in the Senate, said Sen. Mike Hall, who’s currently the minority leader. To be certain, there are people who support repeal, particularly in the House, where one Republican legislator in a leadership position told Governing he’ll definitely put forth a bill. But he can’t count on the Senate. “There will be no move here to get rid of Medicaid expansion,” Hall said. “I don’t know what the house will do, but it’s not an issue I hear people talking about.” 

In Arizona, at the moment it appears more likely Medicaid expansion will be struck down by the courts than in the legislature. The Arizona Supreme Court hears oral arguments today in a suit brought by a group of conservative lawmakers against Gov. Jan Brewer, arguing the expansion violated a constitutional amendment that limits new taxes in the state. 

Most legislative leaders didn’t return requests for comment, with the exception of outgoing Speaker Andy Tobin, who declined to discuss next steps lawmakers might take until after the suit. Political journalists in the state say they don’t see repeal to be a likely scenario, and Governor-Elect Doug Ducey said in a debate that he’d veto a repeal effort, at least in the near term. 

For governors, who can’t afford to be as ideologically rigid because they have to appeal to statewide audiences, it’s politically perilous to take away coverage for thousands of people if they want to win a second term, said David DiMartino, a national Democratic political consultant, in a previous interview. 

“It’s political suicide to take that away from that population,” he said. “Anger is a very efficient organizing tool.” 

Chris covers health care for GOVERNING. An Ohio native with an interest in education, he set out for New Orleans with Teach For America after finishing a degree at Ohio University’s E.W. Scripps School of Journalism. He later covered government and politics at the Savannah Morning News and its South Carolina paper. He most recently covered North Carolina’s 2013 legislative session for the Associated Press.
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