Expanding the Umbrella: Medicaid Expansion 2015 Review and New Year's Preview

With 2016 right around the corner, and several new governors moving into office, it's as good of time as any to take stock of where the Medicaid expansion has gone and the prospects for progress in the new year.  Despite massive Democratic setbacks at the state level in the 2014 midterm elections, Medicaid expansion fared reasonably well in 2015, and 2016 posts several opportunities for new states to expand as well, as well as one at risk of backsliding.

First, we visit the ghosts of Medicaid expansion past:

As Chart I shows,  the ACA Medicaid expansion has proceeded at a similar overall pace to the original Medicaid take-up in the late 1960s, though the holdouts to Obamacare are likely to offer stiffer resistance than the late adopters of the initial program.

Democratic defeats in the 2014 elections likely prevented expansions in Maine and possibly Florida, and may have influenced resistance to expansion plans in several other states, including Tennessee, Utah and Wyoming. However, Four new states joined the expansion -- Indiana, Pennsylvania, Alaska, and Montana -- which increases the number of states fully expanding Medicaid from 26 to 30. 

Head below the fold for state-by-state analysis and a peak at 2016.

With Bel Edwards win, Louisiana set to expand Medicaid

A quiet legislative maneuver from last Spring combined with an unexpected triumph of Democrat John Bel Edwards in the governor's race makes it nearly certain the Louisiana will become the 31st state -- and second in the former confederacy --  to expand Medicaid.

On Saturday, Edwards, who strongly favors expansion, easily defeated sitting U.S Sen. David Vitter in Louisiana's gubernatorial run-off election (after throwing this haymaker on the airwaves). Edwards' replacement of Bobby Jindal in itself removes a massive obstacle to the Medicaid expansion, as Jindal is an implacable (and inexplicable) foe of covering 242,000 uninsured Louisianans.

However, the state legislative majorities remain firmly in GOP hands in Louisiana. This phenomenon has stalled governors who have wanted to accept the expansion: just ask Jay Nixon in Missouri, Terry McAuliffe in Virginia and (until recently) Steve Bullock in Montana.

But the good news is that the legislature in Louisiana already has acted. Well, sort of. The legislature has rejected multiple bills expanding Medicaid in 2013, 2014 and 2015. However, in 2015 both houses passed a joint resolution laying out circumstances under which the state can expand Medicaid. The resolution creates a mechanism under which -- if a new governor assents -- the department of health and hospitals will set a fee on hospital systems to fund any state portion of the Medicaid expansion. Hospitals will likely be fine with this, as the bill exempts the smallest providers and in any case accepting federal Medicaid dollars will pump a much greater amount of funding back into the system.

In short, the legislature isn't exactly pushing for an expansion, but it is devolving its power to set up a mechanism under which a governor can chose to take it. That's exactly the opposite of what Texas did in 2013, when it took away the governor's power to accept the expansion in order to make it less likely that the state would take it.

So in any case, at least we're stumbling forward toward doing the right thing -- after we've tried everything else, of course, but I'll take it.  

Finally, note that this happening is further evidence of two important points.

First, Republican resistance to the Obamacare remains strong and widespread, but continues to slowly erode at the state level.

Second, quite simply is that elections still matter. Each of the four major contenders in the Louisiana gubernatorial race, including the three Republicans, expressed openness to expanding Medicaid. However, Edwards was the most consistent and strident supporter of expansion and is the least likely to impose conditions on expansion that would hurt recipients.

Medicaid Expansion Keeps Stumbling Forward -- and Proves Surprisingly Resilient

With the results of the 2014 elections, the pace of Medicaid expansion has become frustratingly slow for progressives.  However, the overall picture has two very important positive points for those seeking to provide universal health care in this country. First, despite meeting several setbacks and roadblocks recently, the expansion continues to grind ahead –excruciatingly slowly, but ahead all the same -- to new states. Second, recent developments in Arizona and Arkansas suggest that a state’s expansion may be durable even in states that get taken over by hard-right governments.

On the first point, Indiana joined the parade of Conservative states expanding Medicaid under a waiver in January. Pennsylvania, under its new Democratic Governor Tom Wolfe, has thrown out the complicated waiver plan submitted by outgoing governor Tom Corbett and is replacing it with a traditional expansion more congenial to beneficiaries (elections matter). Frustrating setbacks have happened in Tennessee and Wyoming, when legislative committees defeated plans negotiated by their governors to expand Medicaid, at the behest of an Americans for Prosperity pressure campaign. However, Utah and Montana are still considering their own plans – and Kansas(!) of all places looks like it may join soon too. Vox, as usual, has the snappy summary.

The second point is more interesting and, for now, just as encouraging. In 2013, Arkansas had negotiated an expansion with waivers under Democratic Governor Mike Beebe to mollify the Republican-controlled legislature. However, it looked like the plan might not survive new Republican Governor Asa Hutchinson and a much larger and more conservative Republican majority elected in 2014. But Hutchinson got behind the program with a few tweaks and convinced the legislature to approve it for another two years while forming a committee to seek a new waiver in 2017.   

In Arizona, the situation appears more ambivalent. Outgoing Republican governor Jan Brewer choose to expand Medicaid in 2012 over howls of protest from conservatives in her legislature. Incoming Governor Doug Ducey has suggested he’s against the expansion, while conservatives made gains in the Arizona statehouse in 2014. Medicaid expansion looked doomed.

But an in-depth examination of legislation Ducey just signed trying to curtail the expansion is instructive. The legislation consists of two Republican pet rocks: attaching work requirements to Medicaid recipients, and limiting beneficiaries to five years total of receiving Medicaid before throwing them off the program. It’s an ugly bill. But notice that the law doesn’t eliminate the expansion, it only attempts to modify it with issues a GOP legislator could plausibly defend as “common-sense reforms.”More importantly, any of these changes would have to be negotiated with the Federal Department of Health and Human Services.

At least for the next two years, those negotiations are going to go like this:

ARIZONA: “We want you to give us a waiver to create work requirements for beneficiaries and throw them out of Medicaid after five years” (hands over proposal).

HHS SECRETARY BURWELL: “Would it annoy you if I did this?” (Folds proposal into paper airplane and tosses it back at Arizona’s forehead)

The bill binds Arizona state officials to go back to the Feds every year and beg for the waiver.  Those conversations are going to go like this:

ARIZONA: “We want you to give us a Medicaid waiver to…”

BURWELL: (Takes proposal. Blows nose on proposal. Crumples it up and hands it back)

What we have here is Politics 101: it allows Arizona Republicans to both whine loudly about how horrible the federal government is, while looking like they are doing something to fight the dastardly Obamacare Medicaid expansion by writing sternly worded letters. They also get to quietly take advantage of all its benefits (including federal funding) that will remain at least as long as a Democrat controls the White House.

So at first glance, at least, the Medicaid expansion is looking surprisingly resilient, even in its infancy. Despite the poor results of the 2014 elections, the expansion continues to meander forward in several states. And every state that takes the expansion may have quite a hard time getting rid of it. This stickiness is good news for justice and for hundreds of thousands of people who get access to health care.

Boggs hearings represent mere hiccup -- Obama judge picks continue confirmation surge

There’s been a lot of frustration among Progressives over Republican senators continuing to block Obama judicial picks in committee thanks to the blue slip method.  The latest manifestation of the frustration comes with the nomination of Michael Boggs, a Republican-backed candidate nominated as part of a deal to fill several slots on federal bench in Georgia (In return for nominating Boggs and two other district appointments, Georgia’s Republican Senators agreed to allow the nomination of Jill Pryor to move forward for the 11th Circuit Court seat and Leigh Martin May for a district judge seat.)

Progressives' frustration is understandable – as a state judge and legislator Boggs has defended voter identification laws, displaying the Confederate flag and opposed gay rights. However, Democrats should also keep their eyes on the forest through the trees: with the elimination of the filibuster for most executive nominations last November, judicial confirmations have drastically increased.

How much?  In 2014, the Senate has confirmed 40 judges thus far – 33 in the district courts and seven in the appellate courts. During the first five years of Obama’s presidency, the previous high number of judges confirmed through the end of May was 24 (in 2011 and 2012).  That translates into an increase of 67 percent in the number of judicial confirmations. Oh – and we’ve still got another week of Senate business to go in May. 

In addition, the vacancy rate is also starting to decline noticeably on the federal bench.  At the beginning of December, just after the Senate eliminated the filibuster, there were 86 vacancies on the district and circuit courts. That number increased on February 1 to 96 openings – likely because GOP obstruction forced Obama to resubmit every nomination, forcing a fresh round of committee hearings. However, by the beginning of March, the number of vacancies was beginning to fall and has continued to decline ever since. By May 20, the number of vacancies had declined to 67, a decrease of 30 percent from its February high (See figure).

Again, this happening doesn’t mean that everything is rosy.  In some states dominated by conservatives, the process is slow (like in Georgia) or seems entirely hopeless, like in Texas (though the Fifth Circuit court will pick up Texan Greg Costa today).  

And would some one give Jennifer Prescod May-Parker of North Carolina a commission already?

However, even in some conservative states there has been progress.  Four nominees from Florida have cleared committee and await final confirmation after months of obstruction from Senator Marco Rubio. More importantly, Arizona has a functioning district court for the first time in several years as six  nominees received confirmation last week – including Rosemary Marquez, who was first nominated in 2011 and blocked by Arizona's senatorial delegation, and Diane Humetewa, the first Native American woman to become a federal judge.

The point is that progressives are right to be frustrated by continuing blocking of some nominations,  however, we should keep it in the back of our minds that nominations are flowing much more quickly now than they were a year ago.