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The big Obamacare news last week wasn't at the Supreme Court. It was in Kansas.

Alex Wong/Getty Images

The Supreme Court got most of the attention on Obamacare this week, as it heard oral arguments in King v. Burwell. While that's an important case, the actual arguments don't change much: court-watchers know it's impossible to ballpark a case off of the single hour of public questioning.

The really big developments on Obamacare — ones that could actually expand coverage — weren't happening at the court. They were happening across the country, in statehouses.  As legislative sessions come to a close, three states are starting to weigh the possibility of signing on to Obamacare's Medicaid expansion.

Kansas, Utah, and Montana all took steps towards the coverage expansion this week, a move that could expand health-care coverage to 297,000 of their low-income residents. They're among the 22 states that have not expanded their Medicaid programs after the Supreme Court made that part of the health law optional in 2012.

One reason states may be considering the program now: the federal government will pick up the entire cost of expansion through 2016. After that, states have to start chipping in a little bit. By 2020, the federal government will cover 90 percent of the costs and expect states to pick up the rest. States that get in early, before 2016, end up getting a better deal.

None of the insurance expansions are a sure shot because of the politics. Kansas and Utah both have Republican governors, who have split on whether to implement a central piece of Obamacare. Montana does have a Democratic governor but also a Republican-controlled legislature (and a difficult history with Medicaid expansion — more on that later). But the fact that the three states are moving in this direction is notable, and important to keep an eye on over the next month as state legislatures reconvene.



(Wichita Eagle via Getty News Images)

Kansas' path toward considering Medicaid expansion is arguably the most bizarre.

The fact that Governor Sam Brownback is open to expansion is a pretty significant shift from the position he's held for the past three years: solidly against participating in the Obamacare program.

As Margot Sanger-Katz of the New York Times noted, Brownback has been one of the program's staunchest opponents. Back in 2012, right after the Supreme Court ruling, she notes that "Brownback's office was the first to tell me it wouldn't expand Medicaid."

This makes his comments this week, where he said his state would consider the possibility of expanding Medicaid, especially notable. "I’ve been pushing that anything we do on Medicaid expansion has to be 100-percent paid for," Brownback said Wednesday while speaking to a group of insurance agents, according to the Lawrence World-Journal.

"I haven’t said we’ll take it. I haven’t said we wouldn’t," Brownback continued. "Last year, I signed the bill that the Legislature passed (saying) that the Legislature had to approve any Medicaid expansion. I think that’s the way to go because it’s going to involve long-term costs. And the Legislature, that’s their primary authority."




Oh, Montana: the state that killed a possible Medicaid expansion in 2013 because a Democratic legislator accidentally voted against it. Yes, this actually happened. I wrote about it back then for the Washington Post:

When the Medicaid expansion bill came up, Republican House Speaker Mark Bladsel motioned for the legislation to be sent back to committee, where many observers expected that it would languish.

Here’s how Hunter describes what happened next. "It was tense," he says. "I’m standing up, I’m appealing the speaker’s decision and he’s reading the rule [that says he can refer it to committee.].

"We had some procedural motions to challenge the speaker. One of our Democratic members pushed the wrong button. That procedural motion failed on a tied vote."

And that hiccup led to the end of Medicaid expansion in Montana — until this week. On Friday, the Montana House is taking up legislation to expand the state's Medicaid program. Governor Steve Bullock, a Democrat, has pushed for the state to expand Medicaid, although it's unclear whether the Republican-controlled legislature will get on board. Montana's rural hospitals have become a force in the discussion, too.

"Hospitals in those states that expanded Medicaid have seen that increased coverage and reduction in charity care, but we have not in Montana," Carla Neiman, the chief financial officer of one local hospital, told the Missoulian. "Our tax dollars are instead helping to fund the broadened coverage in those other states while we still have nothing to offer our needy uninsured."



(Jim Watson/Getty News Images)

The state has spent this legislative session weighing two competing Medicaid expansion proposals. The Utah House has passed a plan called Utah Cares while the Utah Senate signed off on Healthy Utah, a proposal from the governor.

The proposals are different: Utah Cares is a pretty straightforward Medicaid expansion that would extend coverage to roughly 116,000 low-income Utahns. Governor Gary Herbert's proposal, Healthy Utah, would use Medicaid dollars to buy the state's low-income residents private insurance coverage. This is similar to the "private option" policy that Arkansas has pioneered.

The two programs are pretty different, and it's now up to Utah legislators about how (or if) to merge them. Herbert also has the power to decide whether he'll sign off on the law that comes out of the negotiations — or veto it altogether.

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