The question of whether to expand Medicaid, which has divided some state-level and national Republicans, could become an even more vexing issue this year.
Legislatures in multiple states will tackle the question this year of whether to expand Medicaid in order to qualify for federal funding under the Affordable Care Act. How Republicans respond could have a deep impact on the 2016 race for the White House.
Already, 27 states and the District of Columbia have approved Medicaid expansion and the cash infusion from Washington that comes with it, but the remaining 23 have not. Federal taxpayers will shoulder 100 percent of the costs of state expansions through 2017. After that states will have to pick up an increasing percentage of the cost of expansion, though that percentage is intended to go no higher than 10 percent. States are also on the hook for all administrative costs related to expanding the program. Some states, such as Alabama and Texas, have ruled out Medicaid expansion entirely.
But a new crop of states, including — Missouri, Tennessee and Florida — is taking another look at the idea, with percolating proposals for waivers from the Centers For Medicare and Medicaid Services that would let them implement the expansion with some changes.
The latest push has complicated the issue politically, shifting it from a clear-cut litmus test for Republicans nationwide to a more ambiguous fight.
Conservatives and others concerned about increasing federal intrusion in private health warn that potential Republican presidential candidates who oversaw Medicaid expansions in their states, such as New Jersey Gov. Chris Christie and Ohio Gov. John Kasich, could face political repercussions for that decision.
“I think it was a dramatic mistake for them to do that, policy-wise and politically. I think it’ll hurt them,” Americans For Prosperity President Tim Phillips told the Washington Examiner in an interview in November. “I don’t know that it will disqualify them … But I do think it’ll hurt them.”
Some potential challengers have also latched on to the issue as a line of attack.
“I would urge any governor not to be complicit in the disaster that is Obamacare,” Sen. Ted Cruz told reporters after he spoke at an AFP summit in Dallas last year. “It is hurting the American people.”
“It’s like putting 1,000 more people on the Titanic when you knew what was going to happen,” outgoing Texas Gov. Rick Perry said at a Republican Governors Association meeting in late 2013.
But opposing a program that appears to offer free money is a tough stand for prudent executives and legislators to make. Under the expansion, everybody who claims to earn 138 percent or less of the federal poverty rate is eligible for free or heavily subsidized medical care. As more states adopt Medicaid expansion this year, the message is becoming increasingly muddled for Republicans.
“That world,” of Republicans who oppose Medicaid expansion, “gets smaller by the day,” Missouri State Sen. Ryan Silvey told the Examiner.
Silvey, of Kansas City, is himself a Republican in a firmly GOP-leaning state with a Democratic governor, yet he is pushing for the expansion. Silvey met with CMS in Washington last year and said he felt confident that the federal government would approve a waiver for his plan, if it passes.
“Our problem right now is getting past the political discussion,” Silvey said. “The members of the general assembly that are blocking my proposal aren’t debating the issues, they’re just debating the fact that they see this as acceptance of Obamacare. That is the major hurdle.”
Silvey added, “The concept that you can’t be a Republican and come up with a state-focused solution I don’t think holds water.”
The Missouri Chamber of Commerce is among the groups that has backed Silvey’s plan, and the chamber has hired former U.S. Sen. Kit Bond to lobby on its behalf in favor of the proposal.
That doesn’t sit well with fiscal conservatives or those who believe in reducing Washington’s footprint on private health.
Gregg Keller, formerly a senior adviser to the American Conservative Union and, before that, executive director of the Faith and Freedom Coalition, will this week launch the Missouri Century Foundation, a political nonprofit group which will focus in part on blocking Medicaid expansion in Missouri.
“The idea to form this group was born out of the need for a new generation of conservative leaders who could come together to champion free-market initiatives,” Keller said. “Together we have developed a core set of initiatives that we believe are critical to ensuring the economic health of our state for decades to come.”
Among the group’s foundational priorities will be lobbying to prevent the Missouri legislature from approving a Medicaid expansion this year, locally taking up the mantle that has been carried nationally by nonprofit groups such as Americans for Prosperity.
Missouri is not the only state whose local chamber of commerce is pushing the expansion and finding key Republican collaborators. The Florida Chamber of Commerce is lobbying its state legislature to expand Medicaid in the Sunshine State this year, with modifications. Republican Gov. Rick Scott has expressed his support for such a proposal, which would resemble those plans approved in Republican-led states like Michigan and Iowa.
National groups like AFP, and its local affiliates, are working overtime to stymie such plans. In Florida last year, “AFP activists sent more than 13,400 emails to members of the Legislature and Scott warning against the expansion,” the Tampa Bay Times reported.
Silvey is hopeful that he will have the votes this year to pass an expansion in the Show Me State, if his fellow Republicans do not filibuster the proposal — a heavy lift, especially as more outside group’s, such as Keller’s, step up to intervene.
