As Indiana won federal approval to move ahead with its version of Medicaid expansion, other Republican-governed states are lining up with their sketchbooks in hand.
Since the November elections, a half dozen governors have asked their state legislatures to accept Obamacare’s expansion of the federal health insurance program for low-income residents. Four are Republicans who want to opt in but are asking the Obama administration for permission to retool their programs as others have done.
If the administration approves the requests — as it has done for at least five states — the governors could join the growing number of Republican state leaders who have consented to a major part of the Affordable Care Act, even as their party seeks ways to undo the law.
Tennessee Gov. Bill Haslam and Utah Gov. Gary Herbert announced plans in December that would use the extra Medicaid dollars to help low-income residents buy private health coverage. Wyoming Gov. Matt Mead wants to collect monthly premiums from higher-income Medicaid participants and require all to make co-payments.
Last month, Idaho Gov. Butch Otter used his annual address to pitch a plan assigning those with incomes below the federal poverty level to a managed care plan within the state’s existing Medicaid program, while those earning more could sign up for a private health plan in the insurance marketplace.
Republican governors in Alabama and North Carolina have said they might be open to Medicaid expansion. And two other governors in Alaska and Montana, one an independent and the other a Democrat, have recently proposed expanding it.
When the 2010 healthcare law was passed, it required every state to expand Medicaid to low-income Americans up to 138 percent of the federal poverty level — about $33,000 for a family of four. But then the Supreme Court gave states the option of opting out, and 22 states have done so, citing the extra costs they would have to cover.
While every state has a Medicaid program — with some more generous than others — the expansion is part of the Affordable Care Act, which remains relatively unpopular among Americans. And some conservatives say paying for it could prove too burdensome on limited state budgets.
States don’t have to pay for any of the expansion until 2017, when the federal funding will start phasing down until it covers 90 percent of costs for the newly eligible population. They will then have to cover the remainder.
“There’s still 10 percent, and in state budgets that’s a lot of money,” said Nina Owcharenko, director of the Center for Health Policy Studies at the Heritage Foundation.
Ten Republican governors — including Indiana Gov. Mike Pence — have chosen expansion. But many have asked for leeway to use the federal Medicaid dollars for private plans or require beneficiaries to chip in for their insurance or care.
The Obama administration so far has generally granted those requests. Alternative Medicaid programs have been approved in Iowa, Michigan, Pennsylvania, Arkansas and now Indiana. Indiana’s program represents the first time the administration has approved a system that blocks Medicaid coverage for higher-income people who fail to pay their share of premiums.
“Certainly Indiana broke some new ground on premiums in allowing for a lockout,” said Judy Solomon, vice president for health policy at the Center on Budget and Policy Priorities.
But the administration also indicated this month that it is putting a limit on the creativity.
In Utah, Herbert wants to require Medicaid recipients to work. But federal officials said earlier in January that the state won’t be allowed to attach that requirement to collecting the benefits. This week, the Centers for Medicare and Medicaid Services emphasized that again when announcing it approved Indiana’s plan.
“CMS did not approve a work requirement as part of this agreement,” the agency said. “While states may promote employment through state programs operated outside of the demonstration, this is not permitted under the Medicaid program.”
Meanwhile, a large swath of states mainly in the South and Midwest remain opposed to expanding Medicaid. Texas Gov. Greg Abbott has reiterated that he won’t go for it, although he recently requested information about Utah’s alternative plan.
