The ACA initially required all states to expand Medicaid coverage to low-income Americans, which would grow the program’s enrollment from 32 million to 49 million. It would cost the federal government $795 billion in the course of a decade and is largely financed by cutting reimbursement rates paid to doctors who provide services under sister program Medicare.
Federal funds vs. fallout
In a decision that caught supporters of the law off-guard, the Supreme Court ruled that the mandatory Medicaid expansion was an overreach of federal power. It lets states choose whether to participate — and left Republican governors balancing an influx of federal dollars against political fallout.
In Ohio, Kasich’s office worked shoulder to shoulder with Obamacare supporters and opponents, crafting a lobbying campaign aimed at making a key portion of the health overhaul more palatable to businesses and legislators.
“We knew for the extension to even be a possibility, there needed to be a better understanding of it,” Kasich communications director Scott Milburn said. “That case needed to be made by stakeholders on the front lines. Once they got going, it became a persuasive argument. Their ongoing partnership on this is highly valued.”
Rather than having to convince the governor, Obamacare supporters were asked to focus their efforts on convincing businesses and legislators.
“The governor’s office said that, ‘If this is going to happen, I need to see that I’m not going to get creamed by the legislature.’ So it was very clear what we had to do,” said Cathy Levine, executive director of the Universal Health Care Action Network, which supports the health-care law.
Levine recalls her group working on an economic analysis of the Medicaid expansion. In that process, she was in regular contact with the governor’s office, sharing different budget assumptions, to ensure they would all land near the same place.
The Kasich “administration was totally transparent about how they were developing their numbers and analysis,” Levine says. “We went back and forth so we could try to close those differences. They worked very hard on their end on an honest analysis of those numbers.”
Hospitals have been especially aggressive in pushing for the larger Medicaid program, since increasing the insurance coverage will eliminate much of the uncompensated care that they provide.
Arizona’s hospitals volunteered to pay a new tax to finance the state’s Medicaid expansion, which would give the state access to $1.6 billion more in federal funds.
“It’s not the most ideal situation,” Arizona Hospital and Healthcare Association’s Pete Worthheim said. “I think the industry recognizes that if we are going to be successful, we need to bridge differences and close in on something that will work with the state budget.”
Arizona’s Brewer became worried about passing up the Medicaid expansion when she saw that nearly all of her neighboring states — including California, Colorado, New Mexico and Nevada — were opting into the program.
“From Governor Brewer’s perspective, the Medicaid expansion could represent a wealth shift from states that chose not to expand to those that choose to,” Brewer spokesman Matt Benson said. “She looked around at how Arizona would compete regionally, let alone nationally, if we didn’t go forward and ensure that Arizona tax dollars stay in Arizona.”
Since announcing her decision in January, Brewer has had conference calls with other governors explaining her state’s approach to the health-care law. She will soon crisscross the state on a publicity blitz, holding news conferences at local hospitals to rally support for the decision.
“There have been some conversations,” Benson said. “She has been on conference calls with other governors. We have had contact and calls on the staff level with other states, as well.”
Not all Republican governors are sold; 10 have said they will not move forward on the program. But health advocates still believe that, with more of their colleagues enlisting, they could have a shot at changing their minds.
“I think we’re going to see many more states come in fairly soon,” Pollack said. “There are key constituency groups close to Republican governors who are making a very compelling business case that’s hard to ignore.”