Another Election Loser: Obamacare's Medicaid Expansion

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Now that Republicans will be taking control of the Senate, party leaders will get the chance to stage a full vote on the repeal of Obamacare, forcing either a Democratic filibuster or a presidential veto. Either way, it will be pure theater, since there’s no real chance of undoing the law as long as President Obama remains in office. But the results of Tuesday’s election will still have a real impact on the Affordable Care Act’s provisions for state-level Medicaid expansions.

Six governors’ races provided a chance for a change of power that would mean a state that hadn’t already expanded Medicaid might change its mind: Alaska, Florida, Georgia, Kansas, Maine, and Wisconsin. Republicans ran the table with the exception of Alaska, which remains too close to call.

The Affordable Care Act envisioned that all states would widen eligibility for the state-federal insurance program for the poor, helping those who earn too little to get subsidized private coverage under the law. The federal government would pay for most of the cost of expansion. The Supreme Court ruled in 2012 that states didn’t have to expand Medicaid, and so far 22 have decided not to.

That created a coverage gap for people who don’t meet traditional Medicaid criteria but earn too little to qualify for Obamacare subsidies. Between 3 million and 5 million poor, uninsured people fall into the gap. It disproportionately affects blacks and Hispanics, particularly in the South: Alabama, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Virginia, and Texas have all declined to expand the program.

In Arkansas, where Democratic Governor Mike Beebe pioneered a way to use Medicaid expansion funds to subsidize private coverage, the future of that program is in doubt under the incoming Republican governor, Asa Hutchinson.

Republican leaders in moderate states have expanded Medicaid, including Rick Snyder in Michigan (who won last night) and Tom Corbett in Pennsylvania (who lost). Republicans taking over in blue states, including Illinois, Maryland, and Massachusetts, may seek permission from Washington to revamp those Medicaid programs to make them look more like the privatized versions in Arkansas, Indiana, and a handful of other places.

In most states, the GOP gains cement the status quo for Medicaid for the next few years. The losers in that scenario include the millions of people in the coverage gap, as well as hospitals that have to treat the uninsured in emergency rooms without reimbursement. States that have already expanded their programs are unlikely to roll them back, because it means both taking away people’s coverage and giving up money from Washington. That’s a tough move for any new governor to make.

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