*This story has been updated to reflect developments in Kansas.
What’s the point?
That seemed to be the resounding sentiment after the election of Donald Trump from states that had not yet adopted one of Obamacare's key policies. With Republicans in control of the House, Senate and White House, it seemed like only a matter of time before they were finally able to fulfill their goal of repealing and replacing the law formally known as the Affordable Care Act (ACA).
But House Speaker Paul Ryan’s answer to the ACA -- the American Health Care Act -- died without being voted on last Friday. The following Monday, several states where GOP opposition has blocked Medicaid expansion for years suddenly opened to the possibility.
In Georgia, GOP Gov. Nathan Deal announced that he is now open to applying for a federal waiver that would let the state expand Medicaid but with more flexibility. In Virginia, where the Republican-dominated legislature has crushed Democratic Gov. Terry McAuliffe's attempts to expand Medicaid, he is renewing his push. And in deep-red Kansas, the legislature voted to expand Medicaid on Monday. But Gov. Sam Brownback vetoed the bill on Thursday, and lawmakers' attempt to override him fell three votes shy.
Under the ACA, the federal government offers funding for states that choose to make more low-income people eligible for government-sponsored health insurance. Only 31 states have taken the money -- almost all of them led by Democrats. If the GOP's replacement plan had passed, this provision would have ended in 2020.
||No Medicaid Expansion||
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The failure of Congress to replace Obamacare -- at least so far -- may also boost long-shot bids to expand Medicaid in other states.
Idaho and South Dakota, for example, both toyed around with the idea of expansion but ultimately abandoned it once Trump, who promised to repeal Obamacare "on Day One," was elected. Both governors had been hopeful that something could be worked out but faced opposition from the legislature. Those efforts could be revived now that repeal isn't on the immediate horizon.
In Maine, the legislature had passed Medicaid expansion five times -- only to be vetoed by GOP Gov. Paul LePage. This prompted residents to take matters in their own hands, and voters are set to decide the issue in November. But advocates of expansion hope the legislature will act sooner now that the ACA replacement plan collapsed.
“This option isn’t going away, so I hope lawmakers enact the will of the people. If not, then we’ll vote," says Robyn Merrill, spokesperson for Mainers for Health Care, the group spearheading the ballot initiative. "And if the governor tries to undermine that, then we have the law on our side.” (LePage has recently said that he thinks ballot measures are just "recommendations.")
In North Carolina, Democratic Gov. Roy Cooper attempted to expand Medicaid through executive action earlier this year, but the move is currently tied up in the courts.
Medicaid historically had been reserved for only the poorest and sickest, but the ACA opened it up to the lower middle class. States that expanded the program have experienced many benefits. For example, uninsured rates dropped -- dramatically in some states -- as did uncompensated care.
“Medicaid is such a fabric on the health system. Now, there are very few -- if any -- policy reasons not to expand,” says Adam Searing, associate professor at Georgetown University’s Center for Children and Families.
Medicaid expansion has been a highly partisan issue. But the debate at the federal level has revealed that there's more bipartisan support -- among voters and policymakers -- for expanding Medicaid than previously thought. Republican governors arguably scored the biggest win with the demise of Paul Ryan's plan because now they will likely take less political heat for expanding Medicaid and can claim credit for insuring more of their residents.
With the ACA here to stay for the foreseeable future, Searing notes four states worth keeping an eye on: Florida, Georgia, North Carolina and Texas. Once one of those states expand Medicaid, “then the dam breaks,” he says.