At the risk of being overly optimistic, I think we may have reached a tipping point on Medicaid expansion, where it will soon become completely acceptable for Republican states to accept it, insure their poor citizens, and reap the economic and social benefits despite the taint of Obamacare. I'm not saying there won't be holdouts, because there will be. But something is changing.
I'll explain why in a moment, but first, the quick background. (Skip this paragraph if you know all this.) When the Supreme Court decided in 2012 that states could opt out of the expansion of Medicaid included in the Affordable Care Act, some health-care wonks said we shouldn't worry. The expansion was so generous—with the federal government picking up 100 percent of the cost at first, then ratcheting down to 90 percent of the cost over a few years—that it would be insane for any state to turn the money down. In fact, the most conservative states had the most to gain, since their Medicaid eligibility levels were so stingy to begin with, meaning they'd have particularly large numbers of people now with insurance. Despite that, and despite the fact that study after study has shown that accepting the expansion saves states money, there were many holdouts in Republican-controlled states. It turned out that self-interest, and the simple moral imperative to give coverage to a state's most vulnerable citizens, was not enough to overcome most Republican politicians' loathing of Barack Obama and anything associated with him.
But there have been glimmers of hope. Republican governors in nine states have accepted the expansion, though sometimes they have tried to soften the ideological blow by negotiating what is essentially a privatization of Medicaid in the state. The Obama administration and local Democrats have gone along with most of these proposals, because even if it's more convoluted than just signing people up for Medicaid, as far as they're concerned that beats leaving people with no insurance at all. But there are still 19 Republican states that have refused the expansion, and four more (Indiana, Tennessee, Wyoming and Utah) where it's still under discussion.
That brings us to this week, and two developments that may be only rhetorical, but actually have real significance. The first was Ohio governor John Kasich's awkward gyrations over whether the Affordable Care Act actually helps people's lives, during which he said, "I have favored expanding Medicaid, but I don't really see expanding Medicaid as really connected to Obamacare." As absurd as that may be, Kasich has now set a precedent. No one is saying that Kasich's potential presidential campaign is doomed, and other Republican governors will probably use the same argument. Watch Indiana's Mike Pence, who may also run in 2016: If he and Republican legislators finally agree on a plan to expand Medicaid, and he says that it doesn't mean he's any less committed to repealing the hated Obamacare, then you'll know this position has really taken hold.
The second development comes in the North Carolina Senate race. The GOP candidate is state house speaker Thom Tillis, who is as responsible as anyone for the hard right turn the state took after Republicans won control of the governorship and legislature in 2010. In April he ran a radio ad boasting: "Thom Tillis has a proven record of fighting against Obamacare. Tillis stopped Obamacare's Medicaid expansion cold. It's not happening in North Carolina, and it's because of Thom Tillis." Yet in a TV appearance last night, he said the state ought to consider accepting the Medicaid expansion.
If an ideological warrior like Thom Tillis can change his tune on Medicaid, almost any Republican can. What matters, though, isn't so much Tillis' belief as his particular situation. He's in a tough race, trailing incumbent senator Kay Hagan slightly, and trying to convince voters he isn't the crazy ideologue Hagan has made him out to be. And that offers a clue to where we're likely to see change on this issue.
In the next year or two, we may see a whole bunch of states accept the expansion. It will happen where one or more of a couple of conditions get met. The first is where a Republican governor gets replaced by a Democrat. There are five states that have not accepted the expansion in which Republican governors are in extremely tight races and could well lose this November: Maine, Florida, Wisconsin, Georgia, and Kansas. All five Democratic candidates in those states favor Medicaid expansion. Any or all of the states could accept the expansion if a Democratic governor pushes for it.
The second set of states that could accept expansion soon are those that are controlled by Republicans but still have plenty of Democrats in them, making it easier to sort-of go along with a law signed by Barack Obama. The clearest is Virginia, where Democratic governor Terry McAuliffe has so far been unable to persuade a Republican legislature to accept the expansion. The other possibilities among the holdouts are Wisconsin, Missouri, and North Carolina. I'd even throw Montana, Idaho, Alaska, and maybe South Dakota in there, since they're extremely conservative but can also show occasional glimmers of practicality.
That would leave us with seven states where it is going to take a substantial amount of time before they'd be ready to accept Medicaid expansion: Nebraska, Oklahoma, Texas, Louisiana, Alabama, Mississippi, and South Carolina. With the exception of Nebraska, you're basically looking at the South, places where not only is the Republican grip on power as strong as iron, but where the political culture puts a high value on both hating Democrats and kicking poor people.
If it came down to only those seven states without expanded Medicaid, that would still leave many, many people without insurance. In those states alone there are two million people in the "coverage gap," with incomes too high for their state's miserly Medicaid eligibility but too low to get subsidies on the federal exchange (a million of them are in Texas). That's a lot of remaining misery. But it's a lot better than where we are now.