Some States Have Second Thoughts About Refusing Medicaid Expansion

Republican governors from Florida, Michigan, Ohio and Arizona were originally opposed to the health care law, but are now pushing to expand Medicaid. Hari Sreenivasan talks with Ohio Public Radio bureau chief Karen Kasler and Mary K. Reinhartf, reporter for The Arizona Republic, about what’s behind the changes in their states.

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    Now: why some Republican governors who have been vocally opposed to Obamacare are having second thoughts about walking away from an expansion of Medicaid.

    Hari Sreenivasan is back with that story.


    Medicaid is a crucial piece of the health reform law and its goal of providing new coverage to 30 million Americans.

    Roughly 13 million of them are expected to receive coverage by expanding eligibility to the program, which provides health care to the poor. But the calculus changed after the Supreme Court decided states could opt out, even though the federal government would pick up 100 percent of the new costs for the first three years.

    So far, 23 states, mostly led by Democratic governors and the District of Columbia, have said they plan to expand eligibility starting next year. Eighteen others with Republican governors are opposed. Those states could be passing on billions of dollars. Now some Republican governors who have been opposed to the health care law are pushing to expand Medicaid. That includes Florida, Michigan, Ohio, and Arizona, where Governor Jan Brewer signed a bill to do so today.

    We look at what's behind these changes in two of these states.

    Mary K. Reinhart is with The Arizona Republic. And Karen Kasler is with Ohio Public Radio.

    So, Mary K. Reinhart, let me start with you. What did Gov. Brewer have to do, and why did she do it now?

  • MARY K. REINHART, The Arizona Republic:

    Well, she had to get a bipartisan coalition of her Republican-led legislature to go along with what she's announced at the beginning of the legislative session in January that was a top priority. And that was expanding Medicaid.

    It was a surprise, stunned observers, because she had — we were one of the states to sue to stop Obamacare, and the governor needed to get this coalition behind her. She put these folks together. When negotiations stalled, the governor called a surprise special session. And in just 48 hours, this bipartisan coalition in the House and Senate pushed through Medicaid expansion, and got her to where she is today, signing that bill.


    And she still doesn't admit that this is in support of Obamacare, right?


    She admits that this tiny little piece, she supports. She says it's the law of the land. The election certainly was conclusive, with the reelection of President Obama. The Supreme Court made its decision.

    And she is trying — was trying to convince for the last five months opponents in the legislature, both the leaders in the House and Senate, that this was — this was a done deal, and what Arizona needed to do was go along, do the math, look at the calculus, as you say, and realize that we're talking about insuring an additional 350,000 people, bringing in about $1.6 billion dollars in the first year alone, and upholding the will of the voters here in Arizona, who in 2000 said they wanted to expand our Medicaid program to insure people under the poverty level.

    So, we had already had — we had already been an expansion state. The governor said it was just a folly to not go ahead and expand Medicaid.


    All right, Karen Kasler, I want to ask you, what is the state of play in Ohio? Where is Gov. John Kasich now?

  • KAREN KASLER, Capitol Bureau Chief, Ohio Public Radio:

    Well, Gov. John Kasich, like in Arizona, surprised a lot of people when he supported the expansion of Medicaid.

    He has been an opponent of what he calls Obamacare, but he said in his budget he took the avenue of, this was a way to capture 13 billion federal dollars over several year and a way to help Ohio's 1.5 million uninsured Ohioans, many whom are very poor and can't afford health insurance.

    And so he spent a lot of his personal capital trying to get this passed. His proposal, though, went over very, very poorly in the state legislature, which is dominated by Republicans. You have a lot of Republicans in Ohio who are very suspicious of the expansion of Medicaid.

    And so it was stripped out of both the House version and the Senate version of the state budget. Our House speaker had said that, of his 60-member caucus, 20 members — and this is quote from him — "would rather shoot themselves in the head than vote for Medicaid expansion."

    So, right now, what's happening is that's out of the state budget, and it's being considered in a different way. We have a Medicaid expansion bill that has only one backer. But now there's a bill that dropped late last week that has lot of bipartisan support, which would reform Medicaid in Ohio by trying to contain costs and integrate work force development and measure health outcomes. And that appears to be the way that Ohio is going to go, Medicaid reform, rather than Medicaid expansion.


    So, how does this affect his relationship with the legislature, especially with those 20 who would rather do something else?


    Well, it's certainly been an interesting thing to watch, because Gov. Kasich got a lot of what he wanted in his first budget cycle.

    And Ohio is almost completely run by Republicans. There's a supermajority in the House and Senate. And Gov. Kasich is a Republican as well. And so there's been a real push on his part to try to get Medicaid expansion, but there's been a real resistance on the part of lawmakers to do it.

    And so this is kind of seen as maybe a halfway point. The lawmakers who are putting this Medicaid reform bill together are saying that they want to improve the system before we start talking about adding more people to it. And so they are still leaving that door open slightly, but right now the path appears to be toward reform, rather than expansion.


    Mary K. Reinhart, I want to come back to you and ask, how does the hospital industry see this and what kind of influence are they having in the conversation?


    Well, like in other states, I think the hospital industry, the Chamber of Commerce, have been very involved in trying to push Medicaid expansion.

    And they were right on board early on in Arizona. They have been carrying for a growing number of uninsured who are coming through the emergency rooms. We have had couple of Chapter 11 bankruptcies in Arizona. So, today, at the signing ceremony, one state lawmaker, a Republican, said, you have saved rural Arizona, you have saved our hospitals.

    So, clearly, they were on board. They are also going to be paying — they're going to be taxing themselves essentially to help pay Arizona's additional share of Medicaid expansion. So they're in all the way with an additional provider assessment to help pay our share of expansion.


    Karen Kasler, I want to ask, how much money is at stake here? Quite a few members of the GOP in different states have said this first three years, free stuff is great, but that 10 percent is still a lot of money to us later on.


    And Gov. Kasich has said it's about $13 billion dollars over seven years. But that money issue is really critical to a lot of Republicans, who have been on the fence or even opposed to this.

    They feel like expanding Medicaid, and then if there's a chance that the federal government wouldn't somehow follow through, that would be a difficult benefit to take away. And so that's been a lot of the concern from conservatives. And there have been some conservative think tanks that have actually put out reports saying that they're very concerned about the long-term stability of the system.

    And so that has been a real issue here, is, will this money be there when Ohioans need it over time? But the hospital issue is really critical here in Ohio, too. We have a lot of rural hospitals. And we have a lot of urban hospitals. And they're very concerned about their long-term financial stability if Medicaid is not expanded.


    So, Ms. Kasler, I want to ask, what is the timeline here? If the legislation that is making it so far doesn't include the expansion, what is next for it?


    Well, the budget needs to be signed by the end of the month. And that is not going to happen.

    And there's been a concern that if indeed Medicaid expansion wasn't started by June 30, there wouldn't be time to capture all those federal dollars. But I'm told by lawmakers who are behind this Medicaid reform bill that they still think there's a possibility to go back and get some of that money, that there's no rush, that we need to improve the system before we add beneficiaries to it.

    But, certainly, time is of the essence, because the clock is ticking here, and so there's a concern to get it done as quickly as possible. With the budget out of the way, maybe that would move forward. The first hearing for these reform bills is tomorrow. And so there's a chance it will move forward.


    All right, Mary K. Reinhart, quickly to you, too. This isn't the end here. People are proposing ballot measures.



    There's a group of two former conservative GOP senators and some GOP activists. Really, the grassroots that's been opposed to this all along are going to be officially kicking off a referendum drive on Saturday. They're taking out petitions with the secretary of state's office. They have got 90 days to collect about 86,000 signatures.

    If they're successful, our Medicaid expansion bill goes on hold until the next general election. Then there's lawsuits that are soon to follow. It's not over yet.


    All right, Mary K. Reinhart from The Arizona Republic and Karen Kasler from Ohio Public Radio and TV, thanks so much.


    Thank you.