Good news from Louisiana

This is long expected, but it is good news all the same. Louisiana's new Governor, John Bel Edwards (D) just made it official: the state is expanding Medicaid.  Edwards estimates that the expansion will get 300,000 uninsured residents  coverage. 

One of the biggest immediate bureaucratic hurdles left is the result of former governor Bobby Jindal (R) gutting staffing in the state health department, but the incoming director thinks she has found a way to hire the 200 + staffers needed to help process new Medicaid applications.

There may be a few other hiccups, but most of the pieces are in place: this is now primarily an administrative task, not a legislative one.

Let the good times roll!

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.

How much would expanding Medicaid help in states that haven’t accepted the expansion?

Perhaps the single biggest story about the implementation of the Affordable Care Act has been the battle in states deciding whether to accept the Medicaid Expansion. The expansion is perhaps the single most important tool in the ACA’s coverage expansion tool kit. It takes 50 state-based single payer systems and drastically expands eligibility for them, which is the single largest progressive victory in politics since the Great Society. Other important Medicaid reforms drastically streamline the application procedures and eliminated asset tests to draw out formerly eligible people who might have gotten tangled up in the system or not bothered applying because the state made you apply in person on Tuesday between the hours of 2:30 p.m. and 3:04 p.m.

However, the expansion is not some magical talisman that instantly enrolls all eligible individuals. Some people will remain ignorant of the program despite the best outreach efforts, while other will not enroll for any variety of reasons. And more to the point, 24 states hadn’t fully taken advantage of the Medicaid expansion by the beginning of 2015. Pennsylvania, Indiana, Montana and Alaska have all signed on this year, leaving 20 holdouts (half of whom were in the former Confederacy – but I digress).

The cool thing that we have some real data of how ACA has actually performed on the ground over the last two years, we make some interesting dynamic projections of what would have happened had some states accepted the Medicaid, instead of simply discussing the number of people who would be eligible for help under the expansion.

I mean, heck, this Charles Gaba fellow has been counting the people who actually signed up for coverage for two years, I might as well take one shot at figuring out who would have signed up if they could have. 

To accomplish that, follow me below the fold, where I build a simple interactive regression model to project the reduction in the uninsured population in states that haven’t expanded Medicaid. Don’t worry; I’ll label the scary part where I work through the model so you can skip the simple summary where I discuss the results in plain English (but you really should read the model section, it’s rather of important and it makes fun of Bobby Jindal).  

Obamacare moderate emerges from the Louisiana jungle, but why?

Sam Knight, a smart guy who occasionally holds down the Washington Monthly's  Political Animal Blog for the weekend, notes some interesting election results in a Louisiana Congressional election on Saturday. Republican candidate Vance McAllister easily defeated fellow Republican Ned Riser, who was backed by tea-party groups, 59.6 percent to 40.4 percent

Knight argues that the election shows that the tea party is losing sway in its scorched-earth war against the Affordable Care Act, as McAllister suggested that he wanted to work with Democrats to improve the law, and hinted that these stances may show a recognition among GOP voters of the reality of Obamacare. Riser had the backing of other establishment Republican groups as well, while McAllister self-financed his campaign and earned a celebrity endorsement from Duck Dynasty reality-TV star Phil Robertson.

I hope Knight is right, but I suspect that there are some funky electoral dynamics at work here that may explain McAllister's stances.

Louisiana uses a two-stage "jungle primary" system in which a wide number of candidates jump into the first round, and if none win a majority, the top two candidates advance to a run-off. Riser finished first in the primary with 32 percent of the vote, while McAllister had 17.9 percent. (primary results here)

McAllister had more ground to make-up, but he had several avenues to get it:

1. He could try to pick up the votes from the other GOP candidates who got knocked out of the run off, whose support made up 18.2 percent of the votes.

2. He could try to pick up support from voters who supported the Democratic candidates -- none of whom made the run-off, who collectively collected 29.9 percent of the votes.

The math looks pretty obvious here. McAllister can probably keep his primary supporters, pick up at least a sliver of other supporters from eliminated GOP candidates and grab almost all the Democratic voters by running conservative on most issues (God and guns in this case) while speaking some sense on the side about health care.

He was able to increase his vote total by 36,000, while Riser only increased his by 3,800. Turnout only decreased from 21.2 percent to 18.3 percent of registered voters, so my theory at least seems plausible. (Since the results from the run-off aren't official, we don't know official turn out figures from partisans in either party. In any case, in this part of Louisiana those numbers are only marginally useful for our analysis, as Democrats still outnumber the GOP, but often tend to vote for Republicans in large numbers.)

I read this as a short-term tactical move to attract moderate and a few liberal voters in a two-way general election who liked the opportunity to keep a pure tea-partier out of office. Notice how as a federal office holder, he'll have no say in whether Louisiana will expand Medicaid, essentially making his election position a no-cost proposition. He'll have plenty of time to establish his hard-right credentials over a year in Congress during which he'll get to vote "no" on lots of things. Next year as an incumbent, he can run on that record and discard the Democratic part of his coalition.

Finally, as a self-funder, he's not as dependent on either tea-party or other GOP party organizations to put together a campaign, so he might be able afford to drift a bit from party orthodoxy on one issue. 

Incidentally, the Christian Science Monitor article that Knight cites hints at this dynamic as well, though Knight doesn't go into it:

Riser and McAllister largely agreed on many issues. Both opposed abortion, favor strong gun rights and criticize the levels of federal spending and debt.
Their sharpest distinction rested with President Barack Obama's signature health care law.

Both opposed the health overhaul, but Riser wanted only repeal, saying the law will harm businesses and families and can't be fixed.

McAllister said repeal had no chance with Democrats leading the Senate and White House, so he said Congress should work to improve the law. He also wants Louisiana to expand its Medicaid program to give insurance to the working poor, an expansion that Riser opposed.

The positions put McAllister at odds with some tea party supporters but generated support from Democrats who had no candidate of their own in the runoff.

(Italics mine)

Again, I'd love to be wrong here, but I think my theory is just as plausible as Knight's with the data we have.

The more general question is what sort of impact the "jungle primary" has on results, but I don't know too much of the political science on it -- though France has had essentially the same system for years with some odd results from time to time.