Medicaid expansion is a compassion test many 2024 Republican presidential hopefuls fail
There is no excuse for leaving people vulnerable to illness, death and financial ruin. We should all care, even if it costs money.
Jill LawrenceAs governor of South Carolina, Nikki Haley was a firebrand when it came to health care for her low-income constituents. That is, she was fiery in her determination to make sure they wouldn’t get Medicaid coverage if their income was slightly above the federal poverty line, even though the U.S. government was picking up most of the tab for expanding the joint state-federal program.
“Not in South Carolina,” she said in March 2013 at the Conservative Political Action Conference. “We will not expand Medicaid ever. We are going to make sure that we take care of the people that we know best to take care of and we don't need Washington's help to do it." At the time, the uninsured rate in South Carolina was nearly 19%.
Haley and former President Donald Trump are so far the only two official candidates for the 2024 Republican presidential nomination, but they are far from the only GOP prospects who fail a threshold test for empathy and moral leadership: maximizing health insurance coverage for low-income people.
Trump did all he could to shrink access to insurance under the 2010 Affordable Care Act, from cutting funds for publicity and navigation to shortening enrollment periods to allowing premiums, work, compliance reporting and other administrative obstacles known to reduce Medicaid enrollment among eligible people. Many of the GOP governors and former governors considering a 2024 race rejected the ACA’s option to expand Medicaid or won Trump-era waivers to impose complex new requirements.
DeSantis fought coverage on 2 fronts
Florida Gov. Ron DeSantis is Trump’s chief rival so far. As a member of Congress in 2017, he voted for an aggressive repeal of the ACA and its new insurance marketplace, premium subsidies and protections for people with preexisting conditions. As governor, he has rejected the law’s optional Medicaid expansion that would insure everyone with income up to 138% of the federal poverty line ($34,307 this year for a family of three).
As it stands, Florida’s income cutoff for parents is 30% of the federal poverty line (well below the still disgraceful median of 39% in nonexpansion states) and most adults without dependent children aren’t eligible at all.
Now Florida seems to be in a rush to drop as many as 1.75 million people or families who have had continuous Medicaid coverage since March 2020, a federal policy during the pandemic. In 2021, its uninsured rate was 12.1%, the fifth highest in the country.
Former Vice President Mike Pence pushed Medicaid expansion in a “more conservative direction” than any other governor, as Politico put it, when he led Indiana. Recipients must pay income-based premiums (as low as $1 in half of cases) or lose coverage, and they must have cumbersome health savings accounts.
But a federal study published in 2020 concluded that the Indiana plan, one of the most complicated in the nation, did not lead to better health outcomes.
South Dakota Gov. Kristi Noem, who sparked 2024 talk with three Washington speeches in three days last week, was a Medicaid expansion rejector until voters forced her hand last fall. They added it to the state Constitution, making more than 50,000 people newly eligible starting July 1. They include "able-bodied, single males," to Noem's displeasure, but they're probably working and either way, why shouldn't they have health insurance?
Work requirements don't work
Two others testing the 2024 waters, New Hampshire Gov. Chris Sununu and former Arkansas Gov. Asa Hutchinson, inherited expanded Medicaid plans from Democratic predecessors and decided to add work requirements. It did not go well.
Both states faced huge actual or prospective Medicaid enrollment drops. More than 18,000 adult beneficiaries were disenrolled in the first nine months of Arkansas Works, with federal evaluators citing “a pervasive lack of awareness and confusion” about requirements. New Hampshire officials tried but failed to avoid Arkansas’ mistakes. They suspended their program when it seemed that 17,000 people – two-thirds of those subject to the work requirements – would lose coverage in its first two months.
Multiple reports document an infuriating litany of predictable problems. First off, most Medicaid recipients already work, and most of the rest are caregivers, disabled or in school. That leaves about 7% theoretically subject to work and reporting requirements. The Urban Institute published a revealing study of New Hampshire's problems trying to connect with this target group at a time Trump was not making outreach easy.
Some people were homeless, couch surfing or moving often. Some did not receive forms or didn’t understand them. Some had limited internet access or trouble getting certified as “medically frail.” Some couldn't find or afford child care. And some didn’t realize they could make up work hours the following month if they fell short.
Sununu and Hutchinson got lucky. Their glitchy programs are a non-issue thanks to courts suspending work requirements, a Supreme Court that did not take up challenges and President Joe Biden’s revocation of Trump's waivers allowing work requirements.
Expansion is good for health and jobs
Virginia Gov. Glenn Youngkin and former Maryland Gov. Larry Hogan also inherited Medicaid expansions from Democrats. Youngkin called the expansion a “sad thing” in a 2021 primary debate but acknowledged that "it's here" and not going anywhere. Hogan likewise accepted that significant changes were unlikely given Maryland's Democratic legislature.
Republicans who kept or adopted or were forced to accept Medicaid expansion have been able to reap its many benefits: federal money flowing into their states, less uncompensated care and more fiscal stability for hospitals, better health outcomes for patients, lives saved, less patient debt and financial stress, more jobs across state economies, and state budget impacts ranging from costs largely offset by savings, to more than paying for itself.
So how did Haley's state end up? South Carolina's uninsured rate fell after the 2014 launch of the ACA, which let people anywhere with any medical condition buy often subsidized policies, but the rate fell more in states that expanded Medicaid. Haley left to become ambassador to the United Nations in the Trump administration in 2017.
That year, as Trump began his offensive to “totally kill” or at least maim the whole law, the South Carolina uninsured rate rose to 15.2% – putting it in the top 10. Various studies, meanwhile, suggested a Medicaid expansion would have covered 40% of uninsured South Carolinians, saved 200 lives a year and supported 44,000 new jobs from 2014-16.
Kasich's simple Medicaid pitch
There is no excuse for leaving people vulnerable to illness, death and financial ruin. That includes naked political hostility toward a Barack Obama achievement and bewildering indifference to fellow humans, especially if caring about them might cost money.
Former Ohio Gov. John Kasich, himself a past GOP presidential hopeful, got it right years ago in his state and last year on a mission to convert North Carolina Republicans to the cause. He told them about the high proportion of cancer diagnoses in the first Ohio expansion group and asked them to imagine "the chance to reach out and literally hand them a lifeline."
The North Carolinians didn't expand Medicaid last year but they're tackling it again now, perhaps remembering Kasich's encouragement. He said it would be part of their personal legacy and predicted: "You'll have people thanking you forever."
He's right. Sometimes it's just that simple. Except when you're a Republican with 2024 presidential aspirations.
Jill Lawrence is a columnist for USA TODAY and author of "The Art of the Political Deal: How Congress Beat the Odds and Broke Through Gridlock." Follow her on Twitter and Post.News
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