Trump could boost Med­i­caid ex­pan­sion by sway­ing down-bal­lot state elec­tions

Modern Healthcare - - NEWS - By Har­ris Meyer

Mis­souri political ob­servers think Demo­cratic gu­ber­na­to­rial can­di­date Chris Koster (left, de­bat­ing op­po­nent Eric Gre­it­ens) might have a shot at win­ning Med­i­caid ex­pan­sion in the GOP-con­trolled Leg­is­la­ture be­cause he used to be a Repub­li­can.

Democrats run­ning for gover­nor in states that have not ex­panded Med­i­caid are blast­ing their Repub­li­can op­po­nents for the GOP’s re­fusal to ex­tend cov­er­age to low-in­come adults un­der the Af­ford­able Care Act.

Some of those GOP can­di­dates are de­fend­ing the po­si­tion, and oth­ers are keep­ing a low pro­file on the po­lit­i­cally fraught is­sue.

In states that have al­ready ex­panded Med­i­caid, the out­come of the elec­tion could de­ter­mine whether those pro­grams are re­tained or rolled back. Demo­cratic can­di­dates for gover­nor in Mon­tana and New Hamp­shire are run­ning against GOP foes who pre­vi­ously op­posed ex­pan­sion and now want to im­pose more con­di­tions on el­i­gi­bil­ity.

Nine­teen states have so far de­clined to raise Med­i­caid el­i­gi­bil­ity as called for in the ACA. Novem­ber’s gu­ber­na­to­rial and state leg­isla­tive races in a num­ber of states carry high stakes for mil­lions of Amer­i­cans who ei­ther could gain cov­er­age un­der Med­i­caid ex­pan­sion or lose it un­der any roll­back. Those elec­tion out­comes could be af­fected by the pres­i­den­tial con­test be­tween Demo­crat Hil­lary Clin­ton and Repub­li­can Don­ald Trump, many political ob­servers pre­dict.

Clin­ton is lead­ing Trump 45% to 40% in the lat­est polling av­er­ages, and has an 89% chance of win­ning the elec­tion, ac­cord­ing to the New York Times polling shop. Her lead has grown in the weeks since the first pres­i­den­tial de­bate.

Around the coun­try, 27 leg­isla­tive cham­bers could change party hands in Novem­ber, with most of those cham­bers cur­rently held by Repub­li­cans, ac­cord­ing to Gov­ern­ing mag­a­zine. States where a Demo­cratic gu­ber­na­to­rial vic­tory and state leg­isla­tive gains could make a dif­fer- ence in pass­ing or pre­serv­ing Med­i­caid ex­pan­sion in­clude North Carolina and New Hamp­shire, two states where Repub­li­cans cur­rently con­trol both leg­isla­tive cham­bers. Ex­perts say much also de­pends on whether Tea Party-types or more mod­er­ate fig­ures hold the up­per hand in each state’s Repub­li­can Party af­ter the elec­tions.

In North Carolina, “it would be much more likely we’d have Med­i­caid ex­pan­sion if the Demo­crat wins,” said An­drew Tay­lor, a political science pro­fes­sor at North Carolina State Uni­ver­sity. “I don’t think the Repub­li­cans will lose their ma­jor­ity in the Leg­is­la­ture, but the pres­i­den­tial race makes it a lit­tle volatile.”

Two gu­ber­na­to­rial races last fall showed how a party changeover can pow­er­fully af­fect Med­i­caid ex­pan­sion. In Louisiana, Demo­crat John Bel Ed­wards suc­ceeded a fer­vently an­tiOba­macare Repub­li­can and promptly is­sued an ex­ec­u­tive or­der ex­pand­ing Med­i­caid to an es­ti­mated 375,000 low­in­come Louisiana adults who qual­ify. In Ken­tucky, Repub­li­can Matt Bevin suc­ceeded a pro-Oba- macare Demo­crat and quickly moved to im­pose tougher con­di­tions on el­i­gi­bil­ity and ben­e­fits in the state’s ex­pan­sion pro­gram. He has threat­ened to end it if the Obama ad­min­is­tra­tion doesn’t ac­cept his pro­posal.

But some ob­servers say a big­ger fac­tor than gu­ber­na­to­rial races would be a Clin­ton vic­tory in the pres­i­den­tial race. “If Clin­ton wins, that will put a lot of ques­tions about the fu­ture of the ACA to rest, and many states will relook at the is­sue of ex­pan­sion,” said Joan Alker, a Med­i­caid pol­icy ex­pert at Ge­orge­town Uni­ver­sity. A Clin­ton vic­tory, she added, would em­bolden more prag­matic GOP lead­ers who have been in­ter­ested in ex­pan­sion all along, such as Se­nate lead­ers in Flori-

da and the gov­er­nors of Ge­or­gia and South Dakota.

Demo­cratic gu­ber­na­to­rial can­di­dates in Mis­souri, North Carolina and Utah are ar­gu­ing that the Repub­li­cans who cur­rently con­trol most of the levers of power in their states have hurt their res­i­dents by turn­ing down the ACA’s fed­eral con­tri­bu­tions to ex­pand cov­er­age to adults with in­comes up to 138% of the poverty level.

“Two bil­lion dol­lars a year. That’s how much our state Leg­is­la­ture is throw­ing away by re­fus­ing to ex­pand Med­i­caid,” said Mis­souri At­tor­ney Gen­eral Chris Koster, who’s cur­rently out­polling his Repub­li­can op­po­nent Eric Gre­it­ens in the race to suc­ceed Demo­cratic Gov. Jay Nixon. The in­cum­bent, who can’t run again be­cause of term lim­its, tried in vain to get the GOP-dom­i­nated Leg­is­la­ture to ap­prove ex­pan­sion, which could ben­e­fit an es­ti­mated 253,000 Mis­souri­ans. “We sim­ply can’t af­ford not to act,” Koster added.

In North Carolina, where Repub­li­can Gov. Pat McCrory and Demo­cratic At­tor­ney Gen­eral Roy Cooper are locked in a tight race, Cooper has at­tacked McCrory for block­ing ex­pan­sion based on con­ser­va­tive ide­ol­ogy. The gover­nor has sug­gested he’s will­ing to con­sider it but the GOP-dom­i­nated Leg­is­la­ture has balked at ex­tend­ing cov­er­age to the es­ti­mated 377,000 low-in­come res­i­dents who would qual­ify. “I know that ex­pand­ing Med­i­caid will cre­ate jobs and save lives,” Cooper said. “Hun­dreds of thou­sands of unin­sured North Carolini­ans shouldn’t have to wait for the next gover­nor to take ac­tion.”

In Utah, where Demo­crat Mike Wein­holtz is trail­ing Repub­li­can Gov. Gary Herbert, Wein­holtz has as­sailed the gover­nor for “politi­ciz­ing” the Med­i­caid ex­pan­sion is­sue, which could ben­e­fit an es­ti­mated 116,000 adults. Herbert, who tried and failed to get the GOP-con­trolled Leg­is­la­ture to ap­prove a con­ser­va­tive ex­pan­sion model, said “ex­pan­sion of Oba­macare is a prob­lem” for vot­ers.

Mon­tana, New Hamp­shire and North Dakota are states where Demo­cratic can­di­dates are fight­ing to pro­tect their Med­i­caid ex­pan­sions. In Mon­tana, Demo­cratic Gov. Steve Bul­lock, who pushed a con­ser­va­tive ver­sion of ex­pan­sion through the GOP-con­trolled Leg­is­la­ture, is in a close race with Repub­li­can Greg Gian­forte, who pre­vi­ously has backed groups op­posed to ex­pan­sion.

“If Bul­lock is re-elected, Med­i­caid ex­pan­sion is here to stay,” said Jeremy John­son, an as­so­ciate pro­fes­sor of political science at Car­roll Col­lege in He­lena, Mont. “If Gian­forte wins, he’s ex­pressed some qual­i­fied skep­ti­cism.”

In New Hamp­shire, which im­ple­mented a con­ser­va­tive ver­sion of ex­pan­sion, Repub­li­can Chris Su­nunu, who pre­vi­ously op­posed ex­pan­sion, is in a tight race with Demo­crat Colin Van Ostern. They’re vy­ing to suc­ceed Demo­cratic Gov. Mag­gie Has­san, who steered ex­pan­sion through the Leg­is­la­ture in 2014 and is now run­ning for U.S. Se­nate. Su­nunu now says he wants to im­pose work re­quire­ments on Med­i­caid ex­pan­sion en­rollees and move peo­ple out of the pro­gram.

“It’s hard to say what Su­nunu would do,” said Wayne Les­per­ance, a political science pro­fes­sor at New Eng­land Col­lege in Hen­niker, N.H. He noted that Democrats are poised to make gains in state leg­isla­tive races be­cause of the Trump ef­fect. “Part of his cagi­ness is wait­ing to see what the Leg­is­la­ture looks like af­ter the elec­tion.”

North Dakota ex­panded Med­i­caid un­der Repub­li­can Gov. Jack Dal­rym­ple and a GOP-con­trolled Leg­is­la­ture in 2014. Repub­li­can Doug Bur­gum, who’s ex­pected to beat Demo­crat Marvin Nel­son in the race to suc­ceed Dal­rym­ple, has sharply crit­i­cized the ACA and the Med­i­caid ex­pan­sion. He has called it a big tax-and-spend pro­gram that’s bad for the state.

The big­gest prizes for Med­i­caid ex­pan­sion sup­port­ers would be Demo­cratic gu­ber­na­to­rial vic­to­ries in Mis­souri and North Carolina, where Repub­li­can law­mak­ers have firmly re­jected ex­pan­sion un­der the ACA up to now. The Mis­souri Leg­is­la­ture over­whelm­ingly ap­proved a re­cent, nar­rower ex­pan­sion for peo­ple with dis­abil­i­ties or who are 65 or older. And North Carolina is in the midst of a ma­jor over­haul of its Med­i­caid pro­gram.

Even if Demo­cratic gov­er­nors are elected in those two states, political ob­servers are skep­ti­cal that GOP law­mak­ers will re­verse course and em­brace ex­pan­sion. “Maybe Koster, who used to be a Repub­li­can, could work with some of the Mis­souri Repub­li­cans,” said Thomas Rin­gen­berg, a political science pro­fes­sor at Rock­hurst Uni­ver­sity in Kansas City, Mo. “But the Af­ford­able Care Act taint still pre­vents a lot of Repub­li­cans from sup­port­ing ex­pan­sion.”

Af­ter the elec­tion in North Carolina, “if a chas­tened Repub­li­can ma­jor­ity is fac­ing a Demo­cratic gover­nor who wants to do ex­pan­sion and it senses that other Repub­li­cans across the coun­try are sign­ing up, it’s plau­si­ble,” North Carolina State’s Tay­lor said. “But Repub­li­can po­si­tions may dig in even deeper if we have a Pres­i­dent Clin­ton.”

AP PHOTO

The state of Med­i­caid ex­pan­sion

Source: Fam­i­lies USA

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