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Pass. Repeal. Repeat: The GOP Cycle of Defying Voters on Medicaid Expansion

In almost every state where ballot measures to expand Medicaid have passed, Republicans have tried to change the voter-approved laws.

Medicaid Utah
Religious leaders demonstrating against Utah lawmakers' efforts to scale back a voter-approved expansion of Medicaid.
(AP/Lindsay Whitehurst)
In the first several years after the Affordable Care Act (ACA) helped states make more low-income people eligible for Medicaid, it was only Democratic-led states that took the federal government up on its offer. Republicans have since warmed to the idea -- but only on their own terms, and sometimes even if it means going against voters' wishes. 

“It’s not tenable anymore to just say no. [Republicans] are feeling pressure to come up with something, but that something they want is a tool to change the way the Medicaid program works,” says Joan Alker, executive director of the Georgetown Center for Children and Families, which studies Medicaid, the nation's government-run health insurance for the poor.

While some Republicans in Georgia, Oklahoma and Wyoming are exploring the possibility of Medicaid expansion in their states, Idaho and Utah are undoing ballot measures that voters passed in November to expand Medicaid.

This week, Utah GOP Gov. Gary Herbert signed a bill that -- if approved by the federal government -- would only cover people earning up to the federal poverty line and would cap enrollment if the limited expansion costs more than expected. Right now, Utah's Medicaid program is largely limited to children, pregnant women and the disabled. The ballot measure, which passed with 53 percent of the vote, would have expanded Medicaid eligibility to people earning up to 138 percent of the federal poverty line. 

The Centers for Medicare and Medicaid (CMS), however, has rejected proposals like this under the Obama and Trump administrations.

Even if CMS rejects the bill, health policy experts don't believe the state would revert back to the original ballot measure and expand Medicaid traditionally. Alker calls Utah’s legislation “a really confusing bill, one we are still reading through. There are a lot of limitations on state funding and other arbitrary limitations in it."

As with various iterations of federal legislation to repeal and replace the Affordable Care Act in 2017, “[state] lawmakers quickly realized that they couldn’t just repeal [Medicaid expansion], they had to replace it with something. Our concern is that this replacement bill was rushed through,” says Alker.

Idaho is also eyeing a rollback of its citizen-led Medicaid expansion ballot measure. The initiative won handily, with 61 percent of the vote. Outgoing GOP Gov. Bruce Otter endorsed it at the last moment, calling it an “Idaho-grown solution” and arguing that “allowing the health-care coverage gap to persist any longer is not an option.”

But legislation to void the initiative is currently making its way through the Idaho statehouse. Under the ACA, the federal government initially pays for 100 percent of the costs of expanding Medicaid. In 2020, states will be on the hook for 10 percent of the bill. If that federal match changes, Idaho would repeal its Medicaid expansion if the bill being considered becomes law.

Nebraska is the only state where lawmakers have not attempted to undermine a Medicaid expansion measure passed by voters. In 2016, Maine voters were the first to approve Medicaid expansion, but then-GOP Gov. Paul LePage prevented it from taking effect. The state's new Democratic governor, Janet Mills, is implementing it.

Meanwhile, the policy is getting a second look in some states where it was a nonstarter for years.

In Wyoming, the success of these ballot measures spurred lawmakers to introduce a bill that would study the possibility of Medicaid expansion.

“Our leadership is aware of citizen-led initiatives in neighboring states. So we’d rather do something off of good data and good funding streams rather than a random vote,” says state Rep. Sue Wilson, a Republican who supports the bill.

Although the state may study Medicaid expansion, Wilson says it's unlikely to adopt a traditional version.

On Wednesday, Georgia Republican Gov. Brian Kemp unveiled the Patient First Act, a two-page bill that would give the executive branch power to pursue federal waivers for health initiatives. It’s scant on specifics, so it’s unclear whether Kemp intends to enact a customized version of Medicaid expansion.

No Democrats signed onto the bill, signaling they want support for more traditional Medicaid expansion, the Atlanta Journal-Constitution reported. 

After campaigning against Medicaid expansion last year, Oklahoma GOP Gov. Kevin Stitt has softened his stance since getting in office. He now says it's something worth looking into if the state could be granted enough flexibility. The state Senate President Pro Tempore Greg Treat, a Republican, echoed those sentiments to the Associated Press.

"Access to health care is an extremely important issue, and we're going to have those conversations. ... We need to make sure that we as a state can afford whatever solution we come up with, long-term,” he said.

The future of Medicaid in these states in uncertain, but one thing is not: The debate over whether to expand Medicaid -- and how -- will continue to be an “ongoing struggle within the Republican party,” says Alker.

Mattie covers all things health for Governing.

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