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What the GOP's historic—and overlooked—statehouse wins mean for health care

November 6, 2014

    Dan Diamond, Executive Editor

    One big storyline coming out of Tuesday's election: That the results of the state governors' races could affect Medicaid expansion. (I know it's a big storyline, because I read it in the Daily Briefing.) 

    In holdout states like Florida, Georgia, and Kansas, Republican governors either won election or were re-elected, making the Affordable Care Act's Medicaid expansion less likely. 

    But there's another, overlooked wrinkle in play: The GOP won a record number of seats in state legislatures, too.

    As Libby Nelson writes for Vox: 

      Republicans now control state government outright in at least 24 states, one more than they did before the election. They control at least 66 of 99 state legislative chambers nationwide. And they cut the number of states with total Democratic control from 14 to seven — the lowest number since the Civil War.

    What does that mean for health care? Quite a bit, actually.

    Look around the nation at how ACA implementation has played out. In several cases, a Democrat governor that said yes to the Medicaid expansion—which could've brought hundreds of millions or even billions of dollars in federal funds—was stymied by Republican resistance in the legislature.

    • In Missouri: Gov. Jay Nixon wanted to expand Medicaid. His statehouse didn't. So Missouri hasn't.
    • In Virginia: Gov. Terry McAuliffe said he planned to expand coverage to 400,000 people. After the legislature blocked him, he settled for 25,000.

    That governor-legislature disconnect has been a problem in Republican-led states, too. 

    While Gov. Rick Scott's re-election in Florida was widely perceived as a likely defeat for Medicaid expansion in the state, the full story is more nuanced. Scott famously said he would support expanding Medicaid in the state. His plans ran awry when Florida's legislature pushed back.

    "The problem with Medicaid expansion in Florida has always been as much with the legislature as it has been with Rick Scott," the Advisory Board's Piper Su pointed out.

    Piper and I spent some time on Thursday reviewing the implications of the statehouse victories, as we prepared for Friday's discussion on how the midterm election will affect health care. (You're welcome to join us, even if you're not an Advisory Board member; all you need is to click here and be by a computer or phone line at 1 p.m. on Friday.)

    And one other parting thought: New (or bigger) Republican majorities in statehouses also means potential changes to existing programs, even in states where ACA implementation is seemingly a settled question. 

    Arkansas in 2013 moved ahead with the "private option," its version of the Medicaid expansion, but 75% of the state's legislature needs to vote to reauthorize it every year. That's already been a tall order—the private option was barely reauthorized earlier this year—and it's going to get tougher after Arkansas Republicans on Tuesday made major gains in both chambers.

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