Medicaid expansion: Who's next?

Right now, we're all breathlessly watching the Healthcare.gov to see if glitches are getting fixed and people are signing up,  but let's pause from that briefly today and look down the road a bit.

One of the biggest immediate holes in the Affordable Care Act opened up when the Supreme Court ruled that states didn't have to expand Medicaid in order to keep their current federal support. Getting more vulnerable people under the poverty line access to health insurance needs to be  a major priority over the next several years. So which states might can we most effectively organize in to push Medicaid expansion?

Currently, 25 states have embraced the expansion, while 25 are still debating the issue or have rejected the expansion for now. (Three days ago, Alaska became the most recent state to announce that it wouldn't be taking the money).

But just because they say "no" today doesn't mean they'll say "no" tomorrow. As Kaiser Foundation research points out, offering lots of federal money to states eventually got nearly every state to deploy some sort of Medicaid program in the 1960s and 1970s and some sort of CHIP programs (children's health insurance) in the late 1990s.

Oddly enough, the Medicaid expansion of the ACA is getting adopted at almost the exact same pace that the original Medicaid was adopted. After one year of available matching funds in 1966, 26 states had opted into the program. A month before the expansion under the ACA goes live, 26 states are at least tentatively (and mostly firmly) in the expansion camp.

The similarities may end there, as Republican intransigence across a wide swath of the South and West will likely block expansion for the foreseeable future. However, even in some GOP-dominated states like Arizona and North Dakota, the expansion has been adopted, so this provision is not absolute.

More immediately though, there are several very ripe target states activists should focus on for immediate results. I list these below with how many uninsured people would be covered under Medicaid expansion (numbers again courtesy of Kaiser), in rough order of degree of difficulty of passing an expansion over the next two years.



Maine (45,000): Democratic majorities in both chambers of the legislature want it. Conservative Governor Paul LePage hates it. LePage is polling somewhere between an epidemic of crotch lice and a plague of locusts and his political career is on the endangered species list. If the Dems get the governorship, Maine is in -- it really is that simple.

Montana (64,000):  Montana almost expanded Medicaid in early 2013, but a Democratic legislator accidentally voted the wrong way on a procedural motion. Dem. Governor Steve Bullock supports expansion, but there's a bit too much resistance in the GOP-controlled legislature to get it passed in a special session. However, activists are about to file paperwork for a statewide initiative.  Win the initiative and 64,000 Montanans get Medicaid. Time for the good guys to refresh their phone-banking and door-knocking skills.

Virginia  (327,000): Democrat Terry McAuliffe's victory in the governor's race breathed life into Medicaid expansion. McAuliffe wants expansion, and the Senate will be tied or very close.  The problem is the House of Delegates, which Republicans would likely control by a 66-33 count.  McAuliffe's people will have to find a way to convince the chamber's leader to allow a vote on expansion and get 17 Republican Delagates to support the measure. That's tough, but Michigan accomplished it. MacAuliffe would likely have to propose an Arkansas or Michigan-style hybrid plan to extend coverage, but it's possible. Virginia would be the third state in the South, after Arkansas and Kentucky, to expand. This would be a large victory.

New Hampshire (42,000): Governor Maggie Hassan and the Democratic House want expansion and are in talks with the GOP-controlled Senate to expand Medicaid during a special session. Negotiations appear to be close but are stalled on some medium-sized points. We might have to wait two years, but NH is always going to be a good possibility to flip to expansion.

Florida  (1,276,000): Governor Rick Scott sort of wanted it, but the House speaker refused to hold a vote and Scott quickly backed away. Scott is very vulnerable in next year's election and his likely opponent, Charlie Crist, backs the expansion. If Crist wins and the Democrats can make even modest inroads in Republican majorities, Florida will be back in play for expansion, though plenty of cajoling and delicate negotiations would have to precede a vote for what would likely be an Arkansas or Michigan-style plan. Getting Florida into Medicaid would be huge, as it would put three of the four largest states in the union in the expansion. (Texas, as usual, would be the laggard)

Total:  1.754 million additional insured.

Getting the five reasonable targets would mean than more than sixty percent of states embracing were choosing to expand Medicaid and give the program critical momentum. Progressives have an straight forward opportunity to play offense here -- time to get to work.