Under pressure from the health care industry and consumer advocates, seven Republican governors are cautiously moving to expand Medicaid, giving an unexpected boost to President Barack Obama’s plan to insure some 30 million more Americans.
The Supreme Court ruled last year that expanding Medicaid to include many more low-income people was an option under the new federal health care law, not a requirement, tossing the decision to the states and touching off battles in many capitols.
The federal government will pay the entire cost of covering newly eligible beneficiaries from 2014 to 2016, and 90 percent or more in later years. But many Republican governors and lawmakers immediately questioned whether that commitment would last and whether increased spending on Medicaid makes sense given the size of the federal budget deficit. Some flatly declared they would not consider it.
In Florida, where Gov. Rick Scott reversed his position and Wednesday announced his support for expanding Medicaid, proponents say that doing so will not only save lives but also create jobs and stimulate the economy. Similar arguments have swayed the Republican governors of Arizona, Michigan, Nevada, New Mexico, North Dakota and Ohio, who in recent months have announced plans or proposals to expand Medicaid.
The shift has delighted supporters of the law.
"I think this means the dominoes are falling," said Ronald F. Pollack, the executive director of Families USA, a consumer group. "The message is, ‘Even though I may not have supported and even strongly opposed the Affordable Care Act, it would be harmful to the citizens of my state if I didn’t opt into taking these very substantial federal dollars to help people who truly need it."’
Nationwide, Medicaid covers 60 million people, most of them low-income or disabled. The Congressional Budget Office has estimated that 17 million more people could be enrolled if all states took the expansion option. So far, 22 states have said they will expand the program, 17 have opted against it and 11 have not decided, according to Avalere Health, a consulting firm.
Some Republican governors remain opposed to the Medicaid expansion. In her State of the State address, Gov. Nikki R. Haley said, "As long as I am governor, South Carolina will not implement the public policy disaster that is Obamacare’s Medicaid expansion."
Gov. Rick Perry affirmed that "Texas will not expand Medicaid" and said he was proud that Texas did not follow other states "scrambling to grab every tax dollar they can."
The change of heart for some Republican governors has also come after vigorous lobbying by health industry players, particularly hospitals. Hospital associations around the country signed off on Medicaid cuts under the health care law on the assumption that their losses would be more than offset by new paying customers, including many insured by Medicaid.
Politics could also be a factor. Obama won all of those states except Arizona and North Dakota in last year’s presidential election, a fact that might have influenced several of the governors’ decisions. Some of the seven are also up for re-election next year, another possible factor.
Religious leaders have added a dimension to the campaign in some states. The Roman Catholic bishops of Salt Lake City and Little Rock, Ark., for example, have urged state officials to expand Medicaid.
The Obama administration has tried to win over state officials by offering new flexibility to manage Medicaid as they like. On the same day that he agreed to expand Medicaid in Florida, Scott got federal permission to move Medicaid beneficiaries into private managed care plans.
Scott’s support for expanding Medicaid is particularly significant — Florida is the fourth-most populous state — and surprising. A one-time hospital executive, he has been among the most strident critics of the health care law, and his opposition to it was a cornerstone of his 2010 campaign for governor.
The battle is not over, however. In Florida, as in many other states, expansion is subject to approval by the Legislature, whose Republican leaders have expressed misgivings. The legislative session begins next month, and advocates say they plan to press ahead with a lobbying campaign.
Leah Barber-Heinz, a spokeswoman for Florida Chain, a health advocacy group, said it was trying to inform lawmakers and the public about who would benefit from an expansion of Medicaid. More than one-fifth of Florida residents, roughly 4 million of 19 million people, lack health insurance.
Jeanie Vincent of Hawthorne, Fla., who has been uninsured since she lost her job teaching middle school in 2010, would probably be eligible for Medicaid if the state expanded its program. Vincent, 61, fell behind on her mortgage after she got emergency retinal surgery in 2011 and owed $2,000. She owes an additional $3,000 for a knee surgery, which she is paying off at the rate of $10 per month.
Qualifying for Medicaid would provide peace of mind, she said.
"It would be amazing because I wouldn’t have to worry," she said. "What happens if I fall and break something or if I have a heart attack?"
Every few days, state hospital associations and advocates for poor people issue reports asserting that the economic benefits of expanding Medicaid would outweigh the costs. In recent weeks, such reports have been issued in Idaho, Indiana, Mississippi, Missouri, Texas, Virginia and Wisconsin. The existence of such a report was a decisive factor in Ohio, where Gov. John R. Kasich decided to embrace an expansion after months of lobbying by coalitions of churches, hospitals, business groups and others.
Publication of that study — by the Ohio State University, the Health Policy Institute of Ohio, the Urban Institute and Regional Economic Models — was "a major watershed moment," said Ari Lipman, lead organizer of Greater Cleveland Congregations and chairman of the Northeast Ohio Medicaid Expansion Coalition.
The study, Lipman said, helped proponents reframe the expansion of Medicaid as "something that was going to help the state budget, boost the state economy and, at the same time, provide health insurance" to more than 455,000 people by 2022.
Gov. Jan Brewer of Arizona, a Republican, noted an even more striking anomaly last month when she recommended expanding Medicaid. If a state does not expand Medicaid, some U.S. citizens will be unable to obtain health insurance, but some legal immigrants with the same income in the same state could get it.
"For poor Arizonans below 100 percent of the federal poverty level," Brewer said, "only legal immigrants, but not citizens, would be eligible for subsidies."