Indiana Gov. Mike Pence really hates Obamacare. He refused to set up an insurance exchange and, while serving in Congress, voted repeatedly for repeal. But now Pence has found something Obamacare is good for: forcing the Obama administration to agree to conservative Medicaid reforms they might not otherwise consider.
As governor, Pence had the final say on whether his state expands Medicaid to 350,000 Hoosiers — and he wasn't shy about using that leverage with the Obama administration. Pence demanded that, if he were to sign onto the Medicaid expansion, it would only happen if he could use Indiana's controversial, Bush-era Medicaid experiment as a vehicle.
"We made it very clear what our position was: if we were able to see the Healthy Indiana Plan waiver renewed, that we would be willing to continue a dialogue about using [that] as a framework for further discussion," Pence said Monday during a presentation at the American Enterprise Institute.
Pence announced last week that he would endorse the Medicaid expansion, becoming the 10th Republican governor to sign onto the program. He joined the growing ranks of state officials using their sway over a key White House priority to extract significant concessions in how Medicaid works.
"The administration is working very hard to come to agreement with Republican governors where they can," says Tevi Troy, president of the American Health Policy Institute and a former Health and Human Services official in the Bush administration. "Because they want people to sign up for the expansion, particularly a high profile governor like Pence, they're working pretty hard to make compromises."
Six governors — five Republicans and one Democratic — have used the Medicaid expansion as a moment to petition the Obama administration for waivers. These agreements give states permission to make changes to Medicaid that aren't otherwise allowed, like changing the benefits patients receive or allowing a private company to run their health coverage rather than the state.
In giving states this flexibility, there's a tension for the Obama administration: it wants to maintain Medicaid as a safety-net program, with a robust set of benefits, but also give states a chance to experiment with new approaches.
The waivers granted in Medicaid expansion negotiations are reshaping the program. They make the public-insurance program look more like private coverage and rely more on enrollees to manage their own care.
Republicans and Obama are working together on Obamacare. Seriously.
Over the past year, states have proposed a handful of new ways to run their Medicaid expansion programs.
Making Medicaid more like private insurance
Not everything is on the table