Gov. Mike Pence is among a dozen or so Republican governors who have participated in Obamacare’s Medicaid expansion — a decision that has earned him praise from liberals and derision from conservatives.
Amid reports that Trump had likely settled on the Indiana governor as his vice presidential pick, the White House used the moment to praise Pence for his work on Obamacare.
Trump has made the electoral map a lot safer for Republicans by picking Pence, a politician respected for his conservative bona fides in most policy areas. Now, with the party establishment slowly falling in line, they’ll be dusting off their pet policy positions — including repealing Obamacare. And while Trump has been all over the map on health care reform from the sidelines, Pence’s home state of Indiana has been the site of one of Obamacare’s fiercest policy battles.
Pence did expand Medicaid through the health care law, but he attempted to do it on his own terms. He extracted additional flexibilities from the Obama administration in how he wants to run the program, molding it to be a more conservative version of the safety net.
His real-world experience may foreshadow how Republicans would revamp health care should the election swing their way — and offer some insight into what a Trump administration, with Pence as vice president, might do on Obamacare.
Republicans governors have always faced pressure on Medicaid expansion — and Pence has tried to walk a fine line
Medicaid expansion has proved a divisive issue for Republican governors. Of the 31 Republican governors in office, 14 are in states that have expanded Medicaid and 17 have refused. Some in states that have expanded Medicaid, like Kentucky, inherited the program from a Democratic predecessor and are considering repeal.
Pence has come down on the expand side. And even though he did it in a way meant to woo conservative policy wonks — pushing the Obama administration for the flexibility to run Medicaid differently — many were unimpressed.
Pence has attempted to distance himself from the policy decision, repeating again and again that Indiana "will not expand traditional Medicaid." But that hasn’t stopped the conservative blowback.
"Mike Pence gives in and expands Medicaid," one National Review article proclaimed when the expansion happened in May 2014. A writer at the conservative Federalist wrote that "Pence’s ‘Alternative’ Medicaid expansion is the worst one yet."
Pence is clearly aware of how divisive the Medicaid expansion is in Republican circles — and he’s tried his best to distance himself from his own decision to participate.
"I’ve said it before and I’ll say it again — Obamacare must be repealed," Pence said at a May 2014 event in Washington, where he then proceeded to outline his plan to expand Medicaid.
"From the very beginning of my tenure as governor, we've been saying no to the Affordable Care Act in Indiana," Pence said when he announced a deal with the Obama administration. "Medicaid is not a program we need to expand, it is a program we need to change."
Here’s how he put it in a Wall Street Journal op-ed: "We will not expand traditional Medicaid. We have a better alternative in a program that offers Indiana's working poor the chance to get insurance and control their own health care."
Pence isn’t exactly lying here: He did expand Medicaid in a way that made changes to the traditional program (and we’ll dive into those changes in a moment). But the way he talks about Medicaid expansion clearly attempts to distance himself as much as he can from Obamacare — while he also expands one of its biggest programs.
Pence attempted to pull of a "conservative" Medicaid expansion. It did not impress conservatives.
The Obama administration very much wants all states to expand Medicaid. Republican governors have used this as a moment of leverage to ask for flexibility to run Medicaid differently.
Mike Pence is arguably the best example of winning concessions from the Obama administration to change how Medicaid works. He wanted to make Medicaid expansion enrollees savvier medical consumers, with a financial stake in improving their own health.
And he did get the White House to approve changes to the program that no other state has made. Indiana tethers eligibility for Medicaid benefits to enrollees’ ability to pay to a degree that is unprecedented for the safety net program.
Indiana, for example, is now the only state in the country that can take certain benefits away from its lowest-income enrollees (including those with no income at all) if they fail to pay a $1 monthly premium.
It's also only state in which enrollees above the poverty line (individuals who earn between $11,770 and $16,243) can get locked out of their health insurance entirely, for a six-month period, if they fail to pay a $27 monthly premium.
Conservatives have generally liked the idea of making Medicaid enrollees more financially responsible for their health care. But they were unimpressed with Pence’s plan; it didn’t require enough "skin in the game" from enrollees.
For example: The deal Pence struck with the Obama administration only allowed him to take away benefits like vision and dental from low-income enrollees who didn’t pay premiums. But some wanted more basic benefits to be put on the line, too.
"While premiums will be part of the reform, they will be essentially meaningless for those before the poverty line, where most benefits cannot be cancelled for non-payment," Peter Suderman wrote for Reason about the expansion.
Pence also gave up on a request to add a work requirement to Medicaid, which the Obama administration nixed in negotiations. Where Pence saw a big win for reshaping Medicaid, many conservatives saw a watered-down version of a plan that wouldn’t reform Medicaid for the better. And that’s made it harder for Pence to position himself as an anti-Obamacare politician, since he’s actively working on one of Obamacare’s biggest programs.