POLITICO Pro Medicaid expansion may contract After the midterms, there is a renewed assault in some states.

Obamacare’s Medicaid expansion is under renewed assault in the states even as the health law faces threats in Washington from the Supreme Court and a Republican Congress.

A handful of Republican governors said that after the November elections, they’d be open to taking billions of federal dollars to cover millions of their low-income residents under the Affordable Care Act Medicaid expansion. Instead, Medicaid faces possible retrenchment after a Republican tide swept emboldened Obamacare foes into every level of government.


Arizona and Arkansas, for instance, seemed like the top trophies in the expansion push. But the governors who embraced that part of Obamacare are gone, and hundreds of thousands of people could be stripped of their coverage if their successors don’t show the same zeal to defend it.

And the handful of Republican governors who are eyeing some form of expansion face roadblocks. For instance, Mike Pence of Indiana, a potential 2016 presidential contender, is attaching conservative policy elements unacceptable to the Obama administration. His potential 2016 rival John Kasich did expand Medicaid in Ohio but now must whip Republican support to keep it going. The governors of Tennessee, Utah and Wyoming all released proposals, as promised, after the elections. But so far in the two Western states, legislators are balking at taking on any part of Obamacare, even if the feds pick up the tab.

The architects of the Affordable Care Act intended for every state to expand Medicaid up to 133 percent of the federal poverty level, less than $32,000 for a family of four. But the Supreme Court in 2012 made the expansion optional as it upheld the rest of the health law.

In the 27 states (and District of Columbia) that have chosen to expand in some form, broader Medicaid coverage has proved to be a fast way of achieving the law’s central goal of insuring more Americans. In 2014, the Urban Institute found the uninsured rate dropped 36 percent in expansion states, versus 24 percent in the holdouts.

The possible backward movement on Medicaid comes amid uncertainty over the law’s other primary tool for reducing the uninsured: marketplace subsidies. The Supreme Court will decide, probably in June, whether the financial assistance is legal in the 37 states using the federal exchange on HealthCare.gov.

Just a few months ago, advocates anticipated that a new wave of pro-expansion gubernatorial candidates, like Democrats Charlie Crist in Florida and Mike Michaud in Maine, would bring new momentum and electoral mandates to the debate. They expected some new GOP governors to be more open to Medicaid, too.

Instead, ascendant Republicans — many driven into office on anti-Obamacare planks — remain as hostile as ever. And their states still have the bizarre coverage gaps created by the Supreme Court ruling. Many of the poorest Americans have no coverage, while people who are just above the poverty line are getting subsidized through the health insurance exchanges.

Advocates of expansion have touted possible economic benefits for the states, predicting job gains through more demand for health services and hospital solvency. A study by Missouri state officials, for example, found that health-sector jobs grew three times as much in states that expanded than in those that did not. But a December report by the nonpartisan Altarum Institute cast doubt on whether that job growth had anything to do with Medicaid.

“Lots of these states are looking at the numbers and saying, no, they have not produced the jobs, they have not produced the economic growth that everybody thought they would,” said Dennis Smith, CMS’ top Medicaid official in the George W. Bush administration.

In Arizona, Republican Gov. Jan Brewer twisted arms to pass Medicaid expansion, leaving conservatives seething and suing. Tea party-aligned legislators argued that Brewer needed a supermajority to pass the expansion financing and a state court gave the case the green light to go ahead a few weeks ago. Brewer attended a recent hearing in person, but her successor, Republican Doug Ducey, has been conspicuously silent about whether he’ll defend the state’s position.

Arkansas saw the sharpest decrease in its uninsured rate in the country after Democratic Gov. Mike Beebe worked with statehouse Republicans and the federal government to craft an innovative alternative approach. The so-called private option, which uses the federal Medicaid expansion funds to buy private plans on the Obamacare marketplace, was seen as a model for other conservative states looking for an ideologically palatable way to move ahead.

But the plan barely squeaked through the Arkansas Legislature in 2013, and voters fired many of its supporters in November. GAO figures show the program coming in over budget, and it’s hard to see right now how supporters can muster the three-fourths majorities they need in both chambers to continue the program, as required by the Arkansas constitution.

“The people basically said, ‘We don’t want the private option anymore,’” said Republican state Rep. Joe Farrer, analyzing the election results. “I don’t think it will be in the current form it is now.”

Foes are crafting a plan to freeze enrollment as both sides wait for Republican Gov. Asa Hutchinson to weigh in. He’s promised to do so in a major address slated for Jan. 22.

“We’ve got a high, high hurdle to reach,” said Jodiane Tritt, vice president of government relations for the Arkansas Hospital Association. The hospitals say the additional coverage is reducing losses from patients who can’t pay their bills — and softening the blow of other ACA-related funding cuts.

There are people who strongly believe they were sent here to kill Obamacare."

“There are people who strongly believe they were sent here to kill Obamacare,” Tritt said, describing the “PR challenge of fully explaining the difference between the private option and Obamacare itself.”

In Ohio, Kasich keeps trying to draw a distinction between Obamacare and Medicaid expansion — even though Medicaid is part of the health care law. He has said he doesn’t “see expanding Medicaid as really connected to Obamacare.” Kasich has lots of political capital after winning reelection with 64 percent of the vote. But he’ll have to spend a significant portion of it persuading his fellow Republicans in the statehouse to renew expansion after he bypassed them last year to enact it temporarily. The new House speaker, Cliff Rosenberger, is a vocal opponent.

If Kasich does choose to run for president, he could face Pence, his western neighbor, in a GOP primary, and Medicaid could be one thing that sets them apart.

While Kasich stuck with traditional Medicaid, Pence asked the Centers for Medicare & Medicaid Services to approve the “Healthy Indiana Plan 2.0” in July, but the agency has yet to issue an opinion. He wants to charge premiums for people below the poverty line and kick people off Medicaid for months if they don’t pay, two measures that may make the feds balk.

If Pence can win approval, he’ll be able to make the case to primary voters that he found a conservative alternative to Washington. But he’s already faced criticism from his right flank for considering any sort of expansion of a government program, so there’s little motivation for him to concede anything else to the feds.

“We continue to be willing to compromise, but we will not compromise the principles of the Healthy Indiana Plan,” said Pence spokeswoman Christy Denault, including “personal responsibility and accountability.”

Utah Gov. Gary Herbert is having similar challenges in his effort to include work requirements as a condition for making able-bodied adults eligible for expanded Medicaid. CMS rejected that in preliminary negotiations, and Herbert presented the plan to state lawmakers anyway. But a legislative panel refused to endorse it, instead backing a vastly pared-down version. Now Herbert’s back to pressing for a work requirement, bringing it up with both President Barack Obama and Health and Human Services Secretary Sylvia Mathews Burwell last week. That’s a tall order, given that Medicaid has never been linked to work status.

The process of getting a waiver approved by federal Medicaid authorities is “always slower than we’d like, and states would like more flexibility,” said National Governors Association Executive Director Dan Crippen, a former Reagan administration official. “The more flexibility they can show, the better off we all will be.”

Winning the waiver is hardly the end of the story in most states. Governors have to persuade legislators to join their leap of faith in the federal government, which is supposed to pay for all of Medicaid expansion the first three years before gradually phasing down to 90 percent for the long run. A lot of Republicans are skeptical about that commitment. “Obviously, it’s hard to prove to the Legislature that someday, somehow, the federal match won’t go down,” Crippen said.

In Tennessee, Gov. Bill Haslam may have figured out a way to squelch concerns about a revenue crunch. The state’s hospitals have agreed to foot the bill as the federal payments scale down. Haslam’s alternative plan “generally seems to be in line with recent CMS approvals,” wrote Joan Alker of Georgetown’s Center for Children and Families after he released details last week.

With a special session devoted to Medicaid scheduled for February, Tennessee is one of the few states where the momentum favors expansion. There are other rumblings: Alaska’s new independent governor has appointed an official specifically to investigate Medicaid expansion, and Idaho Gov. Butch Otter has called for legislative hearings on an expansion proposal. In North Carolina, Republican Gov. Pat McCrory has said he’s looking at other states’ waiver applications for inspiration.

Elsewhere, efforts have stalled. In Wyoming, Gov. Matt Mead worked out a preliminary deal with CMS, but a legislative committee voted to go with a plan more like Indiana’s. Montana’s Democratic governor released a proposal, but statehouse Republicans turned up their noses. Lawmakers just worked out a compromise that may let them move ahead.

Even New Hampshire’s expansion faces some rollback efforts, though that’s more of a long shot. Right now, the state’s expansion lasts only through 2016, and the midterms put Republicans in charge of both houses of the state Legislature, although the governor is a pro-ACA Democrat.

Advocates are betting that politicians’ reluctance to rescind benefits that people are already getting will protect the coverage, and they point out that states were slow to adopt the original Medicaid program in the mid-1960s. But some acknowledge they had expected more states to have adopted it by now.

“Experience told us that we are not going to achieve 100 percent of the states coming in overnight. It’s going to take a while,” said Ron Pollack of Families USA, which supports Obamacare. Still, he added, he would have expected the list at this point to be longer — and not in danger of getting smaller.

Rachana Pradhan contributed to this report.