After years of rejecting Democratic governors' pleas to expand Medicaid, the Republican-controlled Virginia Senate voted on Wednesday to join the more than 30 other states that have.
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 at least 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.
There are two main reasons the tide has turned in Virginia. Democrats gained seats in the conservative-leaning legislature last fall. And earlier this year, the Trump administration made expansion more enticing for some Republicans by letting states add new eligibility rules, such as work requirements and time limits -- provisions that the Obama administration denied.
The budget, which is expected to pass the state House as early as today and to be signed by Gov. Ralph Northam, includes work requirements for Medicaid.
Without expansion, more than 300,000 Virginians fall into a coverage gap of making too much to qualify for Medicaid but not enough to afford health insurance.
"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,” Chris Peace, a Republican delegate in the Virginia House, told Governing in March. Peace supports expansion with caveats, calling it a way to practice “compassionate conservatism.”
This comes on the heels of reports that Congressional Republicans are poised to resurrect a repeal of so-called Obamacare this summer. They spent the greater part of President Trump's first year in office trying and failing to get rid of it. Congress was able, however, to eliminate a major part of the law -- the requirement for people to have health insurance or face a tax penalty -- as part of the tax bill they passed in December. The Congressional Budget Office predicts that, largely because Congress eliminated the individual mandate, millions more will go uninsured.
Meanwhile, the issue will likely be moving to the ballot box this fall.
Last year, Maine was the first state where voters got a say on Medicaid expansion, and they overwhelmingly approved it. The vote inspired advocates in other states to pursue similar initiatives.
In Maine, though, the Republican governor -- who had vetoed five Medicaid expansion bills and who is often compared to Trump -- has built barriers to implementing expansion. Gov. Paul LePage said he wouldn't implement Medicaid expansion unless the state legislature figures out how to fund it. Attorney General Janet Mills, a Democrat running for governor, said the state could use ongoing tobacco settlement payments, but LePage rebuffed that idea. The deadline to fund the expansion has come and gone.
Last month, advocacy groups filed a lawsuit against the governor, arguing that he legally has to expand Medicaid.
Regardless of what happens in Maine, three other states could vote on Medicaid expansion in November.
When GOP Gov. Butch Otter said in his 2013 State of the State address that he wouldn't pursue Medicaid expansion, that more or less ended any serious conversation about it in the state.
Until this year.
In April, an advocacy group called Reclaim Idaho said they had collected the 56,000 signatures needed to get Medicaid expansion on the ballot this fall. If approved, it would cover an additional 78,000 residents who fall into a coverage gap.
But even if it gets certified, will voters approve of expanding Obamacare in a red state? Probably. A Boise State University poll in December found that 75 percent of residents would support closing the coverage gap.
And unlike in Maine, whoever wins the governor's race in November will likely approve the measure. The Republican candidate for governor, Lt. Gov. Brad Little, said he would honor what voters want. Democractic candidate Paulette Jordan, predictably, supports expansion.
Nebraska Democrats have tried and failed for the past several years to gain any meaningful traction for a Medicaid expansion bill in the legislature. So advocates are taking the issue straight to the voters.
Adam Morfeld, a Democratic state senator, said Maine’s vote last fall gave supporters some hope.
"[Maine's vote] reshapes the debate. My district is one of the top five in the state where people fall in that coverage gap, so I’m constantly hearing about the need for more affordable health care,” Morfeld told Governing last year.
The petition-gathering phase is still underway, but organizers -- a group called Insure the Good Life -- have indicated that they are on track to reach the required 85,000 signatures by July 5.
GOP Gov. Pete Ricketts, who is running for reelection, is steadfastly opposed to Medicaid expansion but hasn't said if he would try to override it if voters approved it. Bob Krist, his Democratic opponent, supports expansion.
To be clear, Utah has already passed some form of Medicaid expansion. Twice. But advocates say it hasn’t gone far enough.
In 2017, the Trump administration signed off on a waiver from Utah to let the state expand Medicaid to a small slice of the chronically homeless and mentally ill suffering from addiction. And earlier this year, GOP Gov. Gary Herbert signed a bill that would depart from traditional Medicaid expansion. It is awaiting federal approval, and officials say it could take up to a year before officials make a decision.
The state is asking to add work requirements, end the expansion if federal officials lower their contribution from 90 percent, and set an eligibility limit that stops at the poverty line, which is $12,140 for a single person.
Herbert signaled a willingness to expand Medicaid more traditionally in the past but couldn’t come to an agreement with the Republican-led legislature.
This fall, Utahans have a chance to vote on full expansion. The group, Utah Decides Healthcare, has collected more than the required 113,000 signatures to appear on the ballot. Polls conducted last fall showed widespread support for traditional expansion, with 60 percent of the state's population in favor.
It's unclear what would happen in the event that the federal waiver is approved and the ballot measure passes.