Dec 26, 2015 · Gov. Dennis Daugaard, a Republican, during his budget address this month in Pierre, S.D. The speech included a proposal to broaden eligibility for Medicaid ...
State-Level Brawls Over Medicaid Reflect Wider War in G.O.P.
Photo
Gov. Dennis Daugaard, a
Republican, during his budget address this month in Pierre, S.D. The
speech included a proposal to broaden eligibility for Medicaid in South
Dakota.Credit
James Nord/Associated Press
WASHINGTON
— This month, John Thune of South Dakota, the No. 3 Republican in the
Senate, voted to repeal major provisions of the Affordable Care Act and
to end its expansion of Medicaid, arguing that the health law was “unpopular and unaffordable.”
A
week later, his state’s Republican governor, Dennis Daugaard, announced
that he wanted to make 55,000 additional South Dakota residents
eligible for Medicaid under the law.
“I know many South Dakotans are skeptical about expanding Medicaid, and I share some of those sentiments,” Mr. Daugaard said. “It bothers me that some people who can work will become more dependent on government.”
“But,”
Mr. Daugaard said, “we also have to remember those who would benefit,
such as the single mother of three who simply cannot work enough hours
to exceed the poverty line for her family.”
In
state after state, a gulf is opening between Republican governors
willing to expand Medicaid coverage through the Affordable Care Act and
Republican members of Congress convinced the law is collapsing and
determined to help it fail. In recent months, insurers have increased
premiums and deductibles for many policies sold online, and a dozen
nonprofit insurance co-ops are shutting down, forcing consumers to seek
other coverage.
But
in Arizona, Arkansas, Indiana, Iowa, Michigan, New Jersey, Nevada and
Ohio, Republican governors have expanded Medicaid under the health care law
or defended past expansions. In South Dakota, Tennessee and Utah,
Republican governors are pressing for wider Medicaid coverage. And
Republican governors in a few other states, including Alabama, have
indicated that they are looking anew at their options after rejecting
the idea in the past.
That has created tension with Washington that some lawmakers can no longer ignore.
“I
am very reluctant to take positions that counter the decisions made by
the governor,” said Senator John McCain, Republican of Arizona, where
more than 78,000 people have gained Medicaid coverage under legislation
signed in 2013 by Jan Brewer, a Republican who was then the governor.
Now, Gov. Doug Ducey, also a Republican, is seeking a federal waiver to
charge premiums and co-payments and create work incentives within the
limits allowed by federal rules.
“The governor and Legislature in my state decided that they wanted” to expand Medicaid, Mr. McCain said.
Joan
C. Alker, a senior researcher at the Health Policy Institute of
Georgetown University, said the divide was “a reflection of the larger
fight in the Republican Party between more pragmatic Republicans,
including governors, and the ideological wing of the party that wants to
stop Obamacare at all costs.”
Tarren
Bragdon, the chief executive of the conservative Foundation for
Government Accountability, said that to governors of both parties,
federal funds looked like “free money.” By contrast, he said,
Republicans in Congress focus on costs to the federal government and
believe that the expansion of Medicaid will not be sustainable or
affordable in the long term.
When
Democrats wrote the Affordable Care Act, they wanted to make Medicaid
available to all Americans under 65 with incomes up to 138 percent of
the poverty level — or $16,240 for an individual. The federal government
pays the full cost for newly eligible beneficiaries from 2014 to 2016
and at least 90 percent after that.
In
2012, the Supreme Court ruled that the expansion of Medicaid was an
option for states, not a requirement. Thirty states have chosen to
expand eligibility, and several others are negotiating with the Obama
administration. But state-level brawls over Medicaid expansion have
mirrored the wider political war over the law.
Gov.
Bill Haslam of Tennessee, a Republican, wanted to use federal Medicaid
money to extend coverage to 280,000 low-income people. His proposal
failed in the spring in the legislature, under attack by conservative
groups like the Koch brothers’ Americans for Prosperity, which urged
voters to “stop Obamacare in Tennessee.”
No
member of Congress has attacked the Affordable Care Act with more zeal
than Senator John Barrasso, Republican of Wyoming. But Gov. Matt Mead of
Wyoming, also a Republican, is urging state legislators to expand
Medicaid to cover thousands of low-income people.
“When
I came into office in 2011, I joined other states in a lawsuit
challenging the Affordable Care Act, and I still don’t like it,” Mr.
Mead said in an interview. “But it’s the law of land. So now I’m trying
to be pragmatic, recognizing that we have about 18,000 people who could
obtain coverage. We have small hospitals that are struggling. Our
federal tax dollars are not headed back to Wyoming, but are paying for
health care in Colorado, California and other states.”
Clinching the case for Mr. Mead is the state’s fiscal plight. Revenue is down because of a steep decline in oil
and natural gas prices. With the expansion of Medicaid, he said,
Wyoming would receive an infusion of federal funds, easing its budget
problems.
In
Arkansas, a centrist Democratic governor, Mike Beebe, found a novel way
to expand Medicaid in 2013, using federal money to buy private coverage
for 220,000 low-income people through the insurance exchange set up
under the health care law. His successor, Gov. Asa Hutchinson, a
Republican, said this month that he wanted to continue the expansion
while adding some conservative features, including premiums and work
incentives.
“I
opposed and continue to oppose the Affordable Care Act,” Mr. Hutchinson
said. But, he added, “we’re a compassionate state, and we’re not going
to leave 220,000 people without some recourse.”
In
Utah, Gov. Gary R. Herbert, a Republican, has been trying for two years
to expand Medicaid in some way that would be acceptable to state
legislators and federal health officials.
Senator
Orrin G. Hatch, Republican of Utah and chairman of the Finance
Committee, has stayed out of the negotiations, but aides said he thought
the expansion of Medicaid under the health law was a terrible idea. His
Republican colleague from Utah, Senator Mike Lee, said, “Medicaid’s
abysmal track record of failing our most vulnerable populations will
only get worse as millions of new, able-bodied adults join the program.”
To
the authors of the law, Republican intransigence in Washington is
baffling. The Senate Democratic leader, Harry Reid of Nevada, said
Republicans in Congress “aren’t listening to their constituents or state
leaders.” The Republican governor of his state, Brian Sandoval,
expanded Medicaid and remains highly popular.
To
this day, many Republicans on Capitol Hill are upset about the way the
Affordable Care Act was adopted in 2010 — rammed through Congress, they
say, without any Republican votes and with scant regard for their
concerns.
Senator
Lamar Alexander, Republican of Tennessee, said he remembered discussing
health care with President Obama in early 2010, but, he said, the
president and congressional Democrats “didn’t take any of my advice and
hardly any of the advice of my Republican colleagues about what the
disastrous outcomes of Obamacare would be.” Medicaid accounts for 30
percent of Tennessee’s budget, he said, and expanding eligibility means
“having less to spend on other priorities like higher education, roads
and schools.”
In swing states like Ohio, the politics of Medicaid have become challenging.
More
than 600,000 Ohio residents have gained coverage under Medicaid since
Gov. John R. Kasich expanded eligibility. In his bid for the Republican
presidential nomination, Mr. Kasich has come under criticism from
conservatives but has defended his action, saying he felt a moral
imperative to help the poor.
Senator
Rob Portman of Ohio is running his first Senate re-election campaign,
in the heat of a presidential election year. He voted with other
Republicans to repeal the federal health care law but is cautious in his
criticism.
“Medicaid
badly needs reform,” Mr. Portman said. But, he added, “we must ensure
that Ohioans who rely on it for health care don’t have a lapse of
coverage.”
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