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After Midterm Wins, Momentum for Medicaid Expansion Slows

Red-state voters supported it in the fall, but Republican lawmakers in other states are still hesitant.

Kansas medicaid
Advocates for expanding Medicaid in Kansas stage a protest outside the statehouse Wednesday. A vote to expand the program fell just short in the Senate.
(AP/John Hanna)


  • Last year, voters in Idaho, Nebraska and Utah approved Medicaid expansion.
  • This year, efforts to expand Medicaid failed to gain enough support from Republican lawmakers in Kansas, North Carolina, Oklahoma and Wyoming.
  • Georgia is the exception, and has made significant moves toward adopting expansion.
Medicaid expansion advocates notched several red-state victories during the midterm elections last year. Voters in Idaho, Nebraska and Utah approved ballot measures to make more low-income people eligible for low-cost government health insurance.

But that momentum hasn't continued into this year's legislative sessions. In almost every state where Medicaid expansion had a chance of passing, the effort faltered. 

Since Medicaid expansion became an option under the 2010 Affordable Care Act, President Obama's signature health reform, 36 states and the District of Columbia have adopted the policy, increasing the number of insured Americans by 12.3 million. 

The holdout states are largely led by Republicans, who worry about the cost and tend to favor scaling back, not expanding, government programs. The federal government initially pays 100 percent of the costs of expanding coverage, and then 90 percent of the costs; states have to chip in the rest.

Of the GOP-controlled states that have expanded Medicaid, many of them did so either through the ballot process or by adding eligibility rules. Eight have received waivers from the federal government to make work or job training a requirement for care and to limit the amount of time expansion patients can have Medicaid. Those kinds of rules were repeatedly rejected by the Obama administration but encouraged by the Trump administration.

One reason Medicaid expansion's momentum has stalled is that a federal court struck down Medicaid work requirements in March. The legal uncertainty has made some lawmakers hesitant to expand. 

“Work requirements need to at least be on the table for other states to consider,” says Matt Salo, executive director of the National Association of Medicaid Directors.

Here's a rundown of where Medicaid expansion stands in states that considered it this year:



Expansion in Kansas seemed inevitable.

The GOP-dominated legislature voted for the policy in 2017, but the bill was vetoed by then-Gov. Sam Brownback, a Republican. When Kansas elected Democratic Gov. Laura Kelly in November, who pledged to expand Medicaid, it seemed to be a sure thing.

But after the House passed an expansion bill, the effort fell short in the GOP Senate by a single vote.

When the vote failed in May, Governing's Alan Greenblatt reported that Senate GOP leaders said they would study the issue more and work on a bill to consider during next year’s session. 

“I vote ‘pass’ because I’m not saying no. I’m saying this policy isn’t ready,” said Senate Majority Leader Jim Denning. 


North Carolina

In North Carolina, Democratic Gov. Roy Cooper is warring with his conservative legislature.

Cooper has said he would veto any budget that doesn’t include Medicaid expansion. On Friday, he did just that, setting the stage for a special session if the legislature doesn't override his veto. While some legislators have indicated they might be open to expansion with work requirements and other strings attached, lawmakers said they are “not there yet” on the details. 

One of the biggest reasons for conservatives' hesitation is that the state’s health system is already going through a huge change, says Joe Coletti, a fiscal and tax policy expert for the John Locke Foundation, a right-leaning think tank based in North Carolina. The state’s Medicaid program is shifting to a managed-care program at the end of the year. While managed-care programs save money in the long-run, the transition can be disruptive.

“It’s going to be a learning curve,” says Coletti.



Medicaid expansion has been a tough sell in deeply conservative states like Oklahoma, but this year, a bill passed a legislative committee -- a feat that would have been unheard of a couple years ago.

The bill, however, didn't make it further before the legislative session ended. Advocates are now turning their attention to the ballot. They are confident that if they take the issue to the voters, it will win.

While they still need 178,000 signatures to get the measure on the 2020 ballot, supporters already cleared their legal path: The state Supreme Court ruled this month against a challenge to a potential Medicaid expansion ballot question.

There hasn't been any official polling in Oklahoma, but if the decisive votes in favor of expansion in deeply conservative states like Idaho, Nebraska and Utah are any indication, expansion (in some form) could be coming to Oklahoma in the next couple of years. 



A Medicaid expansion bill also passed a legislative committee in Wyoming this year for the first time.

As in Oklahoma, the Wyoming measure didn't receive a vote in the full House or Senate. Advocates are weighing their options for next year: continue to win over support in the legislature or move forward with a ballot measure?

“We’re gathering our resources and working quietly. I don’t know what we’re going to put forward next year, but it’s still a good idea for Wyoming,” says Marguerite Herman of the Wyoming League of Women Voters, which advocates for Medicaid expansion.



Georgia made more progress toward adopting Medicaid expansion than any other state this year.

Republican Gov. Brian Kemp signed a bill in March that allows him to submit a waiver to the federal government that would tailor Medicaid expansion to his liking. It gives him huge latitude to shape a possible expansion -- a job usually left up to lawmakers.

"I understand and greatly appreciate the trust that has been given to me and my administration by the Legislature with this action," Kemp said at the signing of the bill.

There are no further details about what Medicaid expansion might look like, but it's likely to include work requirements. In fact, the bill forbids Kemp from pursuing traditional Medicaid expansion.

"By passing this legislation we have decided to abandon the status quo," Kemp said. "We are rolling up our sleeves and it is time to get to work."


Looking Ahead to the Future

Salo, the Medicaid directors' representative, thinks that any states that expand Medicaid from here on out will do it through voters -- unless there's a significant change in the political makeup of statehouses. Republicans currently control the legislature and the governor's office in 22 states, and both chambers in another eight.

Salo says holdout states may also be more inclined to expand Medicaid if they could receive the federal funding for only expanding up to the federal poverty line -- an idea that the Trump administration has rejected.

Under traditional expansion, people are eligible for Medicaid if they make 138 percent above the federal poverty line, or $28,676 for a family of three. In states that haven't expanded, people who make well below the poverty line don't qualify for Medicaid. In Mississippi, for example, a family of three can't make more than $3,538 a year; in Alabama, the cutoff is $3,840.

"States are saying, 'Do we have to expand all the way to 138 percent? Why can't we just close that loop and not push all of those people into Medicaid?'"

The rest, they argue, would qualify for tax subsidies to buy private insurance on the health marketplace.

Right now, the Medicaid expansion debate is a battle of two conservative ideologies, says Salo. On the one hand, there’s the desire to curb federal spending, which is likely why the Trump administration rejected the poverty-line waivers, he says. But easing the poverty-line rules would satisfy a different goal of conservatives: pushing more people into private insurance.  


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Mattie covers all things health for Governing.

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