Elections in six states on Tuesday could decide whether as many as 1.3 million more people get health coverage in the years ahead.
There are 15 governor's races this year in states that have declined to expand their Medicaid programs as part of the Affordable Care Act. But we count only the five where the election is likely to make a difference. The races we're watching are genuinely competitive and could result in a policy change if a Republican governor is replaced by a Democrat or an independent. We're also keeping our eye on a sixth state, Arkansas, which has already expanded its program, but where the legislature has to reauthorize the program every year with a three-quarters majority, leaving the program vulnerable to political shifts.
In some of these states, the governor will really decide the state's Medicaid future. In Maine, where the governor has vetoed expansion bills five times, a change at the top would almost certainly lead to expansion. Alaska's choice is also highly likely to be driven by who wins the governor's race.
In other states, even a governor who enthusiastically supports expansion may need to persuade a reluctant legislature. Consider Florida, where Gov. Rick Scott, a Republican, has publicly endorsed expansion but has not persuaded the legislature to go along. His challenger, Republican-turned-Democrat Charlie Crist, says he'll fight harder to get a bill through the legislature, though political watchers in the state are not sure he'd have better luck.
The health law sought to expand Medicaid to every resident earning below an income threshold of about $16,000. But a 2012 Supreme Court decision made the expansion optional. (To get a sense of what the Affordable Care Act might have meant without that ruling - or just to get a sense of what expansion might mean to these states, see our article on what the Medicaid expansion might have looked like.) So far, 27 states and the District of Columbia have decided to expand their programs. The remaining states, all but three led by Republican governors, have decided against expansion.
Here are the states to watch:
Maine
The legislature there has voted for a Medicaid expansion five times, but each time it has been vetoed by Gov. Paul LePage, who is running for re-election. Mr. LePage is in a three-way race, facing Mike Michaud, a Democrat, and Eliot Cutler, an independent. Both have said they would support expanding the program. Polls have had Mr. Michaud and Mr. LePage in a tight race, but Mr. Cutler appeared to free his voters to support a major-party candidate, saying last week, 'Anyone who has supported me, but who now worries that I cannot win and is thereby compelled by their fears or by their conscience to vote instead for Mr. LePage or Mr. Michaud, should do so.' Senator Angus King, another Maine independent, who had endorsed Mr. Cutler, switched his endorsement to Mr. Michaud. An estimated 28,000 people would sign up for coverage by 2016 if the program were expanded, according to estimates from the Urban Institute.
Alaska
Gov. Sean Parnell, a Republican, opposes Medicaid expansion. He has noted that the coverage gap in Alaska is relatively small because many of the people who would become eligible for expanded Medicaid are native Alaskans served by Indian Health Services or veterans served by the Veterans Affairs Department. Mr. Parnell appointed a commission to recommend state-based reforms to close the remaining gap; conveniently, it is set to report back on Nov. 15, shortly after the election.
Bill Walker, an independent candidate running with support from most Democrats, supports the expansion. He notes that Medicaid is more comprehensive than coverage from the V.A. or from Indian Health Services, and that accepting Medicaid dollars would free up Indian Health Services to spend on other needs. Unlike in some states, Alaska's debate over Medicaid expansion has focused on a lot of technical details and not on broad ideological ideas about government. As such, it's likely that the governor's position will drive the policy choice the legislature makes next year. The Urban Institute estimates that 26,000 Alaskans would gain coverage through expansion.
Wisconsin
Medicaid expansion has been a key issue in the governor's race. The Republican incumbent, Scott Walker, has opposed expansion, and his opponent, Mary Burke, strongly supports it. Mr. Walker notes that Wisconsin already had unusually generous Medicaid eligibility rules before the Affordable Care Act. You can see that in the numbers from the Urban Institute: Expanded Medicaid in Wisconsin would add coverage for 120,000 people; Florida, with about three times the population, would have seven times as many new Medicaid enrollees. Wisconsin's legislature is closely divided, and it's unclear whether Republicans or Democratics will be in the majority.
FloridaIn 2012, Governor Scott announced that he would oppose expansion; in 2013, he changed his position to support it. But he has not pressed the issue in the legislature, where opposition has been led by Will Weatherford, the Republican House speaker. If Mr. Scott is re-elected, the legislature is likely to continue to block Medicaid expansion, especially since the new state House speaker, already selected, has come out strongly against it.
Mr. Scott's challenger, Mr. Crist, has been a fervent supporter of Medicaid expansion and would probably press the issue more aggressively. But he may face similar opposition in the legislature. Mr. Crist has said he may take executive action to expand Medicaid, as governors in some other states have done, but it is not clear that is possible under Florida law. Coverage for 848,000 people is at stake, according to the Urban Institute estimate.
Kansas
Gov. Sam Brownback has strongly opposed Medicaid expansion. Paul Davis, a Democrat who is in a close race with Mr. Brownback, has said he wants to find 'a Kansas way' to expand Medicaid, citing other states that have used waivers from the federal government to build a custom Medicaid expansion. But even if he wins, he'll have to get approval from a Republican-held legislature that passed a law last year barring any governor from accepting expanded Medicaid dollars without explicit legislative approval. About 100,000 Kansans stand to gain coverage if Medicaid is expanded.
Arkansas
Gov. Mike Beebe, a Democrat, and the state's Republican-led legislature developed one of the country's most innovative compromises on Medicaid in 2013, known there as the 'private option.' The state uses federal Medicaid dollars to buy private health plans for its low-income residents. Enrollment in the program has been significant - more than 200,000 people have already signed up - but to stay in place, the expansion must be authorized by the legislature every year by a three-fourths majority. This year, Mr. Beebe worked hard to keep expansion in place, and the program was reauthorized with no votes to spare in the state senate. There's an open governor's race (Mr. Beebe is leaving because of term limits), and there are several contested legislative races that, depending on their outcome, could make it harder to find the votes for the program next year. About 205,000 people have already gotten coverage through the program, and would lose it if the expansion were not renewed.
Pennsylvania
Pennsylvania will definitely have expanded Medicaid next year, but election results may determine the shape of the program in future years. Gov. Tom Corbett, a Republican, and his legislature have adopted an expansion to start in January, under a federal waiver with some rules that Democrats in the state oppose. Mr. Corbett is expected to lose badly to his Democratic opponent, Tom Wolf; if Democrats pick up many legislative seats, it's possible they will put their own stamp on the expansion format, though probably not right away.
Other States
In the other states where state governments have rejected expansion, election results aren't likely to matter much. Governor's races in Alabama, Idaho, Nebraska, Oklahoma, South Carolina, South Dakota, Tennessee, Texas and Wyoming are not competitive. In Georgia, the incumbent Republican governor may lose, but the state's Republican legislature passed a law blocking any future Medicaid expansion without explicit legislative approval.
There are also states without governor's races this year where Medicaid expansion could happen in 2015. Utah's Gary Herbert is reportedly in final talks with the federal government about terms for expansion. It appears that Utah, like Arkansas, will use federal Medicaid money to buy private health plans; it may also require beneficiaries to participate in work training. Indiana's Mike Pence has also been negotiating with federal officials, though he does not seem to be as close to a deal. In Virginia and Missouri, Democratic governors support expansion but have had little luck with their legislatures so far.
