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The failure of Republican efforts to repeal Obamacare doesn’t just preserve insurance coverage for the 22 million or so people who have gained coverage under the legislation. It could mean that millions more will gain coverage in the future.
That’s because 18 states have still refused to adopt the Medicaid expansion included in the legislation. Doing so would expand Medicaid to 4.5 million people in those states alone, and at least 90 percent of the costs would be borne by the federal government. When these states’ governors and state legislatures anticipated Republican repeal of the Affordable Care Act, refusing to join in on expanding Medicaid made at least some sense. But with the ACA “the law of the land,” to quote House Speaker Paul Ryan, the case against expansion now looks a lot weaker.
Future elections can always change the trajectory of Medicaid expansion. Democratic victories in the gubernatorial elections of Louisiana and North Carolina led to those states moving toward expansion. Medicaid expansion is a ballot proposition this November in Maine, and gubernatorial and legislative elections in 2017 and 2018 could push through expansion in a wide number of states.
Already, after the repeal effort’s failure, the Kansas state Senate has passed legislation approving expansion (that the governor is expected to veto), and the Republican governor of Georgia has expressed interest in taking action on Medicaid, while being very vague about what that would look like. But millions of Americans live in other non-expansion states and have gotten less clarity.
To see if the status quo is changing elsewhere, Vox asked Republican governors and state legislative leaders in the 18 holdout states for comment. Here’s what they said.
Texas
People gaining Medicaid: 1,099,000, per Kaiser Family Foundation.
Uninsured rate for people under 65: 18 percent
Governor: Greg Abbott (R)
Where it stands: Abbott, like his predecessor Rick Perry, opposes expanding Medicaid. He has not made public statements on the matter since the Obamacare repeal effort failed, and his office has not replied to repeated requests for comment.
Florida
People gaining Medicaid: 799,000
Uninsured rate for people under 65: 15 percent
Governor: Rick Scott (R)
Where it stands: Scott has been all over the place on Medicaid expansion. He expressed opposition early in his first term as governor before endorsing expansion in February 2013. But he never followed up and pushed for a law that would adopt the policy, and the state legislature took no action. Once he was reelected and in his second term in 2015, Scott reversed course yet again and expressed opposition to efforts by some in the legislature to expand.
He has not issued a public statement on the topic since the failure of the repeal effort, and his office has not replied to a request for comment.
Georgia
People gaining Medicaid: 483,000
Governor: Nathan Deal (R)
Uninsured rate for people under 65: 16 percent
Where it stands: Deal has resisted Medicaid expansion, but in the days since the Obamacare repeal effort failed, he has indicated he wants federal approval for major changes to Medicaid, without detailing what exactly what those changes would be.
Jen Talaber Ryan, Deal’s deputy director of communications, said, “The governor is exploring a variety of solutions that bring Georgians greater flexibility and access to care. No specific proposals have been decided upon, but he will continue working with members of the General Assembly to evaluate all options.”
Tennessee
People gaining Medicaid: 227,000
Governor: Bill Haslam (R)
Uninsured rate for people under 65: 13 percent
Where it stands: Haslam has attempted to push through an alternative model for expanding Medicaid in 2015, but fell short due to opposition from conservatives in the legislature. More recently, House Speaker Beth Harwell and allies have proposed a plan for gradually expanding Medicaid, starting with veterans and people with mental illnesses and then expanding to all people eligible under the expansion.
Haslam’s office has not responded to a request for comment.
Virginia
People gaining Medicaid: 226,000
Uninsured rate for people under 65: 11 percent
Governor: Terry McAuliffe (D)
Where it stands: McAuliffe is a strong supporter of Medicaid expansion and has already said he will push once more for expansion due to the collapse of Obamacare repeal. But there are Republican majorities in both houses of the legislature.
The House Republican leadership said in a statement that they "remain strongly opposed to implementing ObamaCare's Medicaid expansion in Virginia. We rejected expansion in 2013, 2014, 2015, 2016, and again in 2017 because it was the wrong policy for the Commonwealth. The lack of action in Washington has not changed that and in fact, the uncertainty of federal health policy underscores the need to be cautious over the long term."
South Carolina
People gaining Medicaid: 223,000
Governor: Henry McMaster (R)
Where it stands: McMaster, like his predecessor turned UN Ambassador Nikki Haley, has long opposed Medicaid expansion in the state. His office did not reply to a request for comment.
Alabama
People gaining Medicaid: 199,000
Uninsured rate for people under 65: 12 percent
Governor: Robert Bentley (R)
Where it stands: Alabama is still not interested in expanding Medicaid, according to Bentley’s communications director, Yasamie August: “Governor Bentley remains optimistic there will be another bill that will repeal and replace the Affordable Health Care Act. The Governor is also focusing on Alabama’s efforts to reform Medicaid by providing managed care through Regional Care Organizations.”
Mississippi
People gaining Medicaid: 164,000
Uninsured rate for people under 65: 15 percent
Governor: Phil Bryant (R)
Where it stands: Bryant has consistently opposed Medicaid expansion, and his communications director, Clay Chandler, says nothing has changed: “Gov. Bryant remains adamantly opposed to Medicaid expansion.”
Missouri
People gaining Medicaid: 150,000
Uninsured rate for people under 65: 10 percent
Governor: Eric Greitens (R)
Where it stands: Former Democratic Gov. Jay Nixon tried and failed to adopt Medicaid expansion, and Greitens campaigned on a vociferously anti-expansion platform last year. As governor, he has proposed large cuts to the existing Medicaid program.
Greitens told reporters on Tuesday that he still opposes expansion.
Oklahoma
People gaining Medicaid: 140,000
Uninsured rate for people under 65: 15 percent
Governor: Mary Fallin (R)
Where it stands: After years of opposing expansion, Fallin briefly entertained the idea of expanding Medicaid last year, but the initiative quickly fell apart. Fallin’s spokesperson reiterated her opposition to expansion: “Oklahoma is not considering expanding Medicaid. Medicaid costs are spiraling nationwide and we must reform the system to slow the cost and reduce fraud.”
Kansas
People gaining Medicaid: 91,000
Uninsured rate for people under 65: 11 percent
Governor: Sam Brownback (R)
Where it stands: While the state House and state Senate have passed measures accepting the expansion, Brownback is against it, according to communications director Melika Willoughby: “To expand ObamaCare when the program is in a death spiral is not responsible policy. Kansas must prioritize the care and service of vulnerable Kansans, addressing their health care needs in a sustainable way, not expanding a failing entitlement program to able-bodied adults.”
Overriding the veto would require picking up a few more supporters in both the House and Senate.
Wisconsin
People gaining Medicaid: 87,000
Uninsured rate for people under 65: 8 percent
Governor: Scott Walker (R)
Where it stands: Wisconsin is an unusual case, as Walker chose not to accept Medicaid expansion funds but to still expand the program to cover adults up to 100 percent of the poverty line; that limits how many people could benefit from the state expanding further.
Walker still refuses to accept the expansion funds, telling the Milwaukee Journal Sentinel on Monday that his position remains unchanged: "My goal is not to put more people on Medicaid. My goal is to get people off." To that end, he is pushing for federal permission to let the state drug-test Medicaid beneficiaries, charge premiums, and put time limits on Medicaid enrollment.
Utah
People gaining Medicaid: 60,000
Uninsured rate for people under 65: 11 percent
Governor: Gary Herbert (R)
Where it stands: Herbert supports expanding Medicaid, but his efforts to pass a plan enacting it have fallen short due to conservative opposition in the legislature. Herbert did sign into law a more modest measure expanding the program to add 9,000 to 11,000 Utahns living below 60 percent of the poverty line last year. Herbert has said since the Obamacare repeal effort that he hopes the Trump administration will grant the state flexibility that allows it to expand further on its own terms.
State Senate President Wayne Niederhauser reiterated his opposition to Medicaid expansion in an email to the news site Utah Policy after the repeal effort fell apart, saying, “The risks [of expanding] are still out there.”
Idaho
People gaining Medicaid: 52,000
Uninsured rate for people under 65: 13 percent
Governor: Butch Otter (R)
Where it stands: After initially opposing expansion, Otter eventually proposed expanding primary care access to people lacking coverage, and funding the expansion with state funds rather than federal money. A Republican effort for an even more modest expansion of about $10 million is currently underway in the state legislature.
Otter’s office did not reply for a request for comment.
Maine
People gaining Medicaid: 44,000 (2015 estimate)
Uninsured rate for people under 65: 6 percent
Governor: Paul LePage (R)
Where it stands: LePage has consistently opposed expanding Medicaid, vetoing a bill in 2014 that would’ve adopted the expansion. The state could still expand if a ballot initiative this November passes.
LePage said on Tuesday that he was interested in creating a state health care system to replace the Affordable Care Act, though he offered no details on what that would look like.
Nebraska
People gaining Medicaid: 42,000
Uninsured rate for people under 65: 10 percent
Governor: Pete Ricketts (R)
Where it stands: Ricketts — a multimillionaire heir to the Ameritrade fortune, and the brother of Trump's deputy commerce secretary-designate — has consistently opposed Medicaid expansion. His office did not respond to a request for comment.
South Dakota
People gaining Medicaid: 29,000
Uninsured rate for people under 65: 10 percent
Governor: Dennis Daugaard (R)
Where it stands: Initially an opponent of expansion, Daugaard warmed to the idea in late 2015 through most of 2016 and worked on a plan to expand, only to reverse course after the election following a meeting with then-Vice President-elect Mike Pence, which convinced him Obamacare would just be repealed anyway.
“Governor Daugaard is not considering Medicaid expansion at this point,” Kelsey Pritchard, Daugaard’s communications director, says. “The governor has always said that expansion would require support from the state legislature. At the federal level, healthcare remains very much in flux.”
Wyoming
People gaining Medicaid: 16,000
Uninsured rate for people under 65: 11 percent
Governor: Matt Mead (R)
Where it stands: Mead supports Medicaid expansion, and has tried repeatedly to pass it, falling short in the state legislature each time. In December, he declared that he would not try again in 2017. Neither his office nor that of Medicaid expansion opponent and state House Speaker Steve Harshman responded to requests for comment.
