Medicaid expansion roundup: Where are all the states now?

Since the November midterm elections, many states have made moves to expand their Medicaid programs under the Affordable Care Act (ACA). Some of those states are controlled by Republican governors, even including a few who were staunchly opposed to expanding Medicaid or participated in the lawsuit against the federal government.

Wyoming Gov. Matt Mead (R) probably summarized it best when he said: "Even though I have serious disagreements with the law, this is the current law. How do we as a state make the best of it?" He made the comments during a December forum hosted by the Western Governors Association, reported the Washington Post.

One common theme among the Republican lawmakers who are willing to expand Medicaid is to require the recipients to undergo certain screenings, pay premiums or obtain jobs as conditions of receiving any benefits.

In this special report, FierceHealthPayer compiled updates for what several so-called nonexpansion states have been up to since the midterm elections.


Gov. Robert Bentley (R) said in December that he would contemplate the idea of expanding Medicaid in his state despite staunchly refusing to consider Medicaid expansion during his reelection campaign. However, Bentley clarified that he's interested only in a federal block grant, and that his administration isn't currently drafting a Medicaid expansion proposal to share with the feds, the Birmingham News reported.


Alaska Gov. Bill Walker (I) wants to expand Medicaid in his state, but he faces an uphill battle from the GOP-controlled legislature that has never been willing to consider the idea. Regardless, Walker said that "expanding Medicaid was a high priority for me," during his inauguration speech, adding, "We will begin the wheels in motion today to begin accepting expanded Medicaid."


Although Arkansas became the first state to use Medicaid funds to buy private insurance for consumers eligible for the state-federal health program, the Medicaid expansion program is now on the chopping block. About 213,000 Arkansas residents obtained health insurance as a result of expanding Medicaid. This resulted in the largest single-state decrease in the uninsured rate in the country, dropping from 22 percent in 2013 to 12.4 percent in June.

Despite this success, newly elected Republicans, including incoming Gov. Asa Hutchinson and state Sen. Scott Flippo--who is replacing state Sen. John Burris (R), one of the private option architects--don't support the private option, believing it costs too much money and isn't viable for the long term. Hutchinson has said he will analyze the private option, which must be reauthorized by the legislature every year to "determine whether the program should be terminated or continued." He likely won't make a decision until the end of January.


Gov. Mike Pence (R) proposed in October to expand the state's Healthy Indiana Plan, which functions like a high-deductible plan and health savings account and requires new members to pay $15 to $25 monthly premiums. However, the state failed to file a complete application requesting federal permission to extend the program. Although the Pence administration and federal officials have continued negotiations to reach an agreement and allow the HIP program to move forward, there have been many hang-ups. Pence told the Indianapolis Business Journal that the chief point of contention is the difference between the state's consumer-driven healthcare model and traditional Medicaid.

Despite the issues, Pence said he's not concerned about the timeline to obtaining federal approval for his Medicaid expansion.  "We have been working very diligently from this summer forward to help prepare to implement the Healthy Indiana Plan as soon as the federal government approves it," he said. "I've made it clear to officials [in the District of Columbia] that as soon as they give us the green light on HIP 2.0, we are ready to start implementing that plan in short order."


In Montana, Medicaid expansion remains in limbo as state legislators decide whether to approve or deny Gov. Steve Bullock's (D) proposal. "There'll be some type of Medicaid expansion," Jim Ahrens, a lobbyist with Alliance for a Healthy Montana, told the Billings Gazette. "But conservative legislators will not pass a full government expansion." Bullock wants to expand Montana's Medicaid program through a "Healthy Montana Plan," which would use up to $750 million in federal funds to pay private insurers to administer coverage, reported the Great Falls Tribune.


Pennsylvania opened enrollment for its alternative to Medicaid expansion, which is called Healthy PA and uses private insurers to administer the plans, on Dec. 1 under outgoing Republican Gov. Tom Corbett. The state expected to cover about 900,000 residents--mostly low-income, single, working adults. But Democratic Gov.-elect Tom Wolf opposes the "complicated" alternative and wants to shift to an outright Medicaid expansion that doesn't involve private insurers. If Wolf is able to alter the Medicaid expansion plan, any individuals already enrolled won't lose their coverage.


Gov. Bill Haslam (R) announced an alternative to Medicaid expansion proposal in mid-December, clearing the way for the Republican-dominated state to explore Medicaid options under the ACA. However, the administration was quick to point out, "We aren't expanding Medicaid. We unveiled Insure Tennessee."

Haslam's plan to expand Medicaid in Tennessee is a two-year waiver program with two options. The plan will offer vouchers to individuals who earn about $16,100 to help them buy employer-sponsored coverage. Alternatively, eligible individuals can sign up for plans designed like health reimbursement accounts, though anyone earning above the poverty level would have to pay premiums and copays, the Washington Post reported.


Gov. Terry McAuliffe (D) presented his budget plan to legislators in December with an eye toward expanding the state's Medicaid program. McAuliffe shared his Medicaid-alternative plan in September but quickly met opposition in Virginia's GOP-dominated House. Such strong Republican opposition to Medicaid expansion is why McAuliffe's announcement is mostly considered a symbolic move. In fact, several Democratic lawmakers seek to "create dilemmas for our Republican colleagues, especially those in targeted seats" on key issues, including continuing to push for Medicaid expansion in the state, the Roanoke Times reported.


Gov. Matt Mead (R) says he will push to expand the state's Medicaid program even though he was one of several state leaders to sue the Obama administration over the ACA. Mead has been talking with federal officials about a Medicaid expansion since August 2014, even though he still has concerns.

Mead has been urging the Wyoming legislature to pass a Medicaid expansion proposal that would require all Medicaid recipients to make co-payments, with higher-income members paying premiums up to $50. Although his Medicaid expansion wasn't passed in 2014, several Wyoming legislators appear to consider the issue a priority for the next session.