After five years of failed attempts to expand Medicaid, Utah Gov. Gary Herbert signed a bill last week to do just that. It may come as a surprise that the bill was sponsored by a Republican.
Republicans have historically opposed making more low-income people eligible for the government health insurance program. Under the Affordable Care Act (ACA), President Obama's signature legislation, the federal government pays 90 to 100 percent of the costs for any state that expands. But Republican-led states have been slow to expand Medicaid, and nearly 20 of them still have not.
The Trump administration, however, made expansion more enticing for some Republicans by letting states tack on new eligibility rules, such as work requirements and time limits -- provisions that the Obama administration denied.
“The Trump administration has shown a real willingness to work with us and allow us to come up with our own solutions. This could turn into a movement for states,” says Utah state Rep. Robert Spendlove, who sponsored a Medicaid expansion bill.
Indeed, Utah isn't the only state where Republicans are re-examining the possibility of expansion. A similar effort is underway in Virginia.
Considering President Trump spent most of his first year in office trying to repeal the ACA, he may not have intended to strengthen the law's impact. Nevertheless, hundreds of thousands more low-income people could soon be eligible for Medicaid in these two states.
Utah's bill requires approval from the federal government. It includes several requests that depart from traditional Medicaid expansion: requirements for applicants to prove they are working, volunteering or job training; an end to the expansion if federal officials lower their contribution from 90 percent; and an eligibility limit that stops at the poverty line, which is $12,140 for a single person.
That last request may not be granted.
Last month, the Centers for Medicare and Medicaid Services (CMS) denied a request from Arkansas to trim its eligible population down to just the poverty line. ACA law, however, requires Medicaid expansion to cover residents making up to 138 percent of the federal poverty line, which is an annual income of $16,642 for a single person.
If any portion of Utah's request is denied, Utah House Speaker Greg Hughes told the Salt Lake Tribune that lawmakers would have to take another look at the bill, calling it a "package deal."
Like Utah, Virginia's GOP-controlled Legislature had stalled the governor's hopes of expanding Medicaid for years. But with the option to add more conservative elements, Republicans are now actively supporting it.
Chris Peace, a Republican delegate in the Virginia House who supports expansion but didn't under the rules of the Obama administration, says these new developments give lawmakers more freedom to practice “compassionate conservatism.”
But the road to expansion is rockier in Virginia.
The House passed a budget that included Medicaid expansion with work requirements, while the Senate passed a separate budget standing strong against it. Gov. Ralph Northam, a Democrat, called a special session to hammer out a deal, starting April 11 and ending June 30. Northam favors Medicaid expansion without caveats but has expressed willingness to work with Republican lawmakers on a compromise.
“We want these training programs and annual evaluations [of eligibility] as a symbolic measure to show it’s not a free ride," says Peace. "But in Virginia, if you’re a family of three and making more than $6,700 a year, you don’t qualify for Medicaid now. Can you imagine a family of three getting by on that? That’s just not something I think is doable.”
If the legislature can strike a deal, it’s estimated that 400,000 Virginians would be newly-qualified for Medicaid. In Utah, 70,000 more would be eligible for free or low-cost health care.
Some health advocates, however, aren't pleased with the progress being made.
"We are not going to be supportive of any effort trying to link access to health insurance to a work requirement," Frederick Isasi, executive director of the health advocacy group Families USA, told Vox.
Since the Trump administration signaled a willingness to approve work requirements (and other Medicaid changes), Arkansas, Indiana and Kentucky have received federal approval to implement one. Eight other states either have requests pending or are debating whether to add work requirements to their existing programs.
Research shows that adding work requirements, time limits and other eligibility rules to Medicaid coverage hinders people from enrolling. And in Kentucky, 100,000 people are estimated to lose health insurance once the state's new rules go into effect in July. (A lawsuit, however, is pending to block them.)
Given Virginia’s inability to get this far with the Medicaid expansion debate in the past, other left-leaning organizations take a more pragmatic approach.
“It’s worth celebrating if they get there because it’ll mean hundreds of thousands of people will get coverage. It does look like they’re going to go with a work requirement, and obviously that means some people who can't work, can't find work or can't jump through the extra hoops won't get coverage. But overall, it would be a good thing,” says Jesse Cross-Call, senior policy analyst at the Center on Budget and Policy Priorities.
There are also efforts to get the question on the ballot this year in Idaho, Missouri and Utah, where the voters could expand Medicaid more than lawmakers have. Advocates of expansion are hoping to replicate the success in Maine, where voters last year became the first in the nation to expand Medicaid through a referendum.
Although Republicans have been a roadblock to the ACA, Virginia's Peace notes that the idea that everyone should have some form of health coverage was actually a conservative idea decades ago.
"We don’t want to rewrite history here. These programs were written by the Heritage Foundation, with Mitt Romney pioneering it in Massachusetts. So in a sense," he says, "we’re going back to our roots."
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