WASHINGTON -- The midterm elections are poised to play a pivotal role in whether more states expand Medicaid eligibility, as the number of red state holdouts dwindles.
Governors' races in states such as Florida and Kansas, along with ballot initiatives in Idaho, Nebraska and Utah, are being watched closely by Medicaid experts this year.
The first half of 2018 already marks a monumental shift in Medicaid, the government insurance program for low-income Americans. And we could see the largest number of states in years adopt Medicaid expansion after this fall's elections. But unprecedented changes to the program -- namely, work requirements -- are also beginning to take effect in some states that could shift the program in the other direction and scale back its population.
The expansion of Medicaid in Virginia is giving advocates hope. Democratic Gov. Ralph Northam on Thursday signed a state budget that includes extending Medicaid coverage to about 400,000 people. The move comes after years of expansion efforts by Democrats, who achieved significant gains in the state legislature last year with health care as a key campaign issue.
The case of Virginia, where the 2017 legislative elections trimmed the Republicans' statehouse majority to a razor-thin margin, shows how electoral changes may lead other states to expand eventually, said Ben Sommers, associate professor of health policy and economics at Harvard.
"The implications for the midterm elections nationally are clear," Sommers said. "In states that have yet to expand, if there is a large influx of new legislators and/or governors supportive of expansion, we'll probably see some other states follow suit."
Experts say the recent developments are fueled, in part, by greater certainty of continued federal support for Medicaid, following last year's unsuccessful Republican efforts to repeal and replace the 2010 health care law. Medicaid expansion also established itself as an issue voters are more aware of and that many support, they say.
"After a year or two in limbo without much movement, the state debate over Medicaid expansion is back in full swing," Sommers said.
Kansas is one state to watch. Earlier this year, GOP Gov. Sam Brownback, who stood in the way of expansion despite support for it in the legislature, left to become ambassador-at-large for international religious freedom. A crowded field of candidates is vying for the governorship.
"Kansas' state legislature already passed Medicaid expansion only to fall just short of overriding the governor's veto, so the election there will be critical to determining Medicaid's fate," Sommers said.