For indispensable reporting on the coronavirus crisis, the election, and more, subscribe to the Mother Jones Daily newsletter.





Stephanie Mencimer’s latest Mother Jones cover story showcased the grim impact tea-party-influenced state lawmakers have had in Florida. Under Gov. Rick Scott, the state rejected billions of dollars in federal funding for any kind of Affordable Care Act-related program, with Scott leading the fight against the expansion of Medicaid coverage for the poor. But Scott’s certainly not the only governor to balk at the idea of making public health insurance more inclusive. In the last month, Govs. Tom Corbett (R-Penn.), Pat McCrory (R-N.C.), and Scott Walker (R-Wis.) announced their states would not be expanding Medicaid to cover more low-income, uninsured residents, and Koch-funded super-PAC Americans for Prosperity expressed its support for a bill introduced in the Pennsylvania Legislature that would reject the expanded Medicaid coverage in state code.

Thirteen state governors are refusing to implement Medicaid expansion, despite the fact that it’s being offered with cherries on top: The Affordable Care Act’s timeline guarantees that the federal government would pay for 100 percent of the expansion in its first three years, tapering down to 90 percent of the paycheck by 2020. According to a recent Kaiser Family Foundation report, expanding Medicaid to cover more low-income groups hovering above the federal poverty line in all states would cut the number of uninsured by nearly half nationwide, provided other features of the ACA are implemented.

Most of these governors argue the expansion would be too expensive, even though including the poor would only increase these states’ Medicaid spending by an average of 3 percent over the next decade, and taxpayers will be paying for the federal program anyway. Several of the governors rejecting Medicaid expansion ran for office on anti-Obamacare or tea party platforms, preaching austerity and less federal meddling. Maine’s Gov. Paul LePage, whose state would actually see its portion of Medicaid spending reduced by expanding the program, argued that Maine would not be “complicit in the degradation” of the country’s health care.

Not all GOP governors are rejecting Medicaid expansion—earlier this month, Michigan’s Rick Snyder and Ohio’s John Kasich agreed to let newly eligible groups onto their Medicaid rolls, joining GOP governors from Arizona, Nevada, New Mexico, and North Dakota who support the program’s expansion. Pressure for other governors to concede is mounting—even Florida governor Rick Scott now appears to be keeping the state’s options open. Update, 6:55 p.m. EST: Scott just announced that he will be supporting Medicaid expansion in Florida, reports the Tampa Bay Times. The announcement came hours after the federal government agreed it would allow the state to privatize the service through a state managed care plan.

Here are the players still holding out:

Robert Bentley (R-Ala.)

When it comes to the Affordable Care Act, Bentley did not mince words: “It is, in my opinion, truly the worst piece of legislation that has ever been passed in my lifetime,” the governor said at a luncheon last year. After last year’s presidential elections, Bentley also announced he would not be supporting Medicaid expansion—a move that would add more than 300,000 Alabama residents to Medicaid rolls, according to the Kaiser Family Foundation report. Like his fellow Republican governors, Bentley cited the costliness of covering the poor as the reason he was opposed (expanding Medicaid coverage would cost the state some $771 million), but researchers at the University of Alabama-Birmingham found that opening the program to more low-income groups would actually generate $1.7 billion in state tax revenue over the decade it’s implemented, in addition to $20 billion in new income.

Nathan Deal (R-Ga.)

Georgia has the fifth-highest rate of uninsured residents in the country, and expanding its Medicaid program would accommodate 698,000 new Medicaid enrollees, according to the Kaiser Family Foundation. A report from Harvard Law School reveals that Georgia—like Alabama, Florida, Louisiana, Mississippi, North and South Carolina, Tennessee, and Texas—also has one of the highest rates of new and existing AIDS cases, along with the worst outcomes nationwide, in part because the poor aren’t able to access treatment through the state’s strict Medicaid eligibility requirements.

Butch Otter (R-Idaho)

In July 2012, Otter appointed a 14-member committee to weigh the pros and cons of expanding Medicaid coverage to more of Idaho’s poor. In November, the panel unanimously agreed that the state should accept expansion, arguing that this reform would save the state the money it bleeds in the state-funded ER costs its uninsured residents can’t pay. But in 2013, the governor announced Idaho would not be pursuing Medicaid expansion—despite the fact that the state would only have to spend $261 million to cover up to roughly 100,000 newly eligible Idahoans, receiving $3.7 billion from the federal government over 10 years.

Bobby Jindal (R-La.)

One of the most outspoken critics of Medicaid expansion, Jindal published an op-ed in the Washington Post in January challenging the president to meet with the Republican governors who would prefer to keep Medicaid coverage “flexible,” i.e., thin. With more than 20 percent of its residents uninsured, Louisiana has one of the highest proportions of uninsured in the country, compounded by the fact that the state also maintains some of the nation’s tightest Medicaid eligibility requirements.

Hospitals and Democratic lawmakers alike have lobbied Jindal to change his mind—last December, Sen. Mary Landrieu pointed out in a letter to Jindal that Medicaid expansion could actually save the state some $267 million in unpaid care costs. “I know from your many speeches across the nation during the recent Presidential campaign your steadfast opposition to the Affordable care act,” Landrieu wrote. “However, the election is over.”

Paul LePage (R-Maine)

Uncompensated care in Maine hospitals has doubled over the past five years, according to a 2012 report from the Portland Press Herald. The state is also one of 10 identified by the Kaiser Family Foundation that would see direct savings from implementing Medicaid expansion, as the federal government would pay more for those currently eligible for the program. But last year, LePage announced that Maine would not be expanding its Medicaid program, writing in a letter to Health and Human Services Secretary Kathleen Sebelius: “Maine will not be complicit in the degradation of our nation’s premier health care system.”

Phil Bryant (R-Miss.)

“As governor, I will fight to protect our future,” Bryant wrote in an op-ed in the Washington Times last October. “And that means that I will resist any effort to expand Medicaid in this state.”

Arguing that Medicaid expansion could result in 1 in 3 Mississippians having Medicaid health insurance, Bryant said he’d rather have 1 in 3 residents “earn health care coverage through good-paying jobs.” He also stressed personal responsibility, exercise, diet, and his own crusade to end teen pregnancy—via abstinence education programs. Mississippi has the eighth-highest rate of uninsured people in the country, and, according to Kaiser Family Foundation, some 231,000 Mississippians would newly enroll in Medicaid if expanded. Some state legislators are still hoping to discuss the idea of growing the program through a state Senate bill reauthorizing Medicaid.

Pat McCrory (R-N.C.)

Last week, McCrory announced he would be throwing his weight behind a bill that would reject Medicaid expansion in his state. “It would be unfair to the taxpayers, unfair to the citizens currently receiving Medicaid and unfair to create a new bureaucracy to implement the system,” McCrory said Tuesday. Roughly 1.6 million North Carolinians are uninsured, and the Kaiser Family Foundation estimates that more than 500,000 residents would enroll if the state extended more coverage to the poor.

Mary Fallin (R-Okla.)

While Fallin, like other governors, cited costs as one reason to abstain from Medicaid expansion, the Oklahoma Policy Institute, a nonpartisan think tank, argued that the net gain of Medicaid expansion would be positive, with costs “likely to be largely or fully offset by budget savings” in other state agencies like the Department of Mental Health and Substance Abuse Services. The Center on Budget and Policy Priorities estimates that 225,000 Oklahomans would be newly eligible for expanded Medicaid, and that the state would spend between $549 to $789 million on the expanded program in its first six years.

Tom Corbett (R-Pa.)

“Washington is asking us to expand Medicaid as part of the Affordable Care Act without any clear guidance or reasonable assurances,” Corbett told Pennsylvania state legislators during his budget address on February 5. “It would be financially unsustainable for the taxpayers, and I cannot recommend a dramatic Medicaid expansion.”

Corbett, who helped file a lawsuit against the ACA while he was state attorney general and running for governor in 2010, is up for reelection in 2014—though only 31 percent of the state thinks he deserves another shot, according to a recent Quinnipiac University poll. The rate of uninsured residents in Philadelphia and surrounding counties has doubled in a little over a decade, and Medicaid expansion would enroll more than half a million newly eligible Pennsylvanians for the program’s coverage.

Nikki Haley (R-S.C.)

Like Rick Scott, Haley was swept into office on a tide of tea party fervor. In July of 2012, she announced on Facebook that South Carolina would not expand its Medicaid program, though, like several of the other states on this list, South Carolina has one of the higher proportions of uninsured in the country, with more than 20 percent of its population lacking health care coverage.

Dennis Daugaard (R-S.D.)

Parents of Medicaid-eligible kids who earn more than $9,936 a year make too much to qualify for South Dakota Medicaid. But Daugaard opposes expanding Medicaid to cover more of the state’s uninsured adults, explaining to one local radio station: “I want to stress that these are able-bodied adults. They’re not disabled: We already cover the disabled. They’re not children: We already cover children. These are adults—all of them.” According to a 2012 Kaiser Family Foundation analysis, accepting Medicaid expansion would enroll some new 44,000 South Dakotans for Medicaid coverage, and cost the state a 3.6 percent increase in its Medicaid expenditure over ten years.

Rick Perry (R-Texas)

Perry, like Scott and Jindal, has been an early expansion naysayer, though his state has the highest rate of uninsured in the nation. “To expand this program is not unlike adding a thousand people to the Titanic,” he told Fox News in July of 2012. Perry argued that expanding Medicaid coverage would bankrupt the state, though by investing $15 billion in the expansion, Texas would receive $100 billion in federal funding and cover 1.8 million newly enrolled residents under the program.

Scott Walker (R-Wis.)

Wisconsin’s tea party governor is the latest to join the anti-Medicaid expansion crew, but is also advocating a novel approach: Instead of expanding his state’s Medicaid coverage, which already covered low-income individuals up to 200 percent of the federal poverty line (with an enrollment limit), Walker would hike that Medicaid eligibility back to 100 percent of the FPL, remove the enrollment limit, and set up a health exchange to provide private insurance to other low income groups. As the Washington Post‘s Sarah Kliff points out, this means that Wisconsin will be turning down the federal government’s offer to pay for new Medicaid enrollees.

This article has been revised.