In red states, hospitals push leaders to expand Medicaid

Nevada's governor is first Republican governor to pledge participation

Health care advocates nationwide are lobbying state leaders to opt into the Affordable Care Act's (ACA) Medicaid expansion—even in states where governors have said they will reject it.

Under the ACA, the federal government will pay to expand Medicaid eligibility to people at or below 138% of the federal poverty line in 2014 in every U.S. state. Federal contributions to the expansion will drop to 95% in 2017 and remain at 90% after 2020, according to the ACA.

However, the Supreme Court's ruling on the law allowed states to opt out of the expansion, and nine governors so far have said they will do so. Moreover, HHS on Monday said it would not fund partial Medicaid expansions, an option that some governors had hoped to explore.

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Regardless, some health policy experts believe states that have pledged to reject the expansion will change their tune. "My guess is that in a lot of these states that have walked away from expanding Medicaid, their people are going to discover that they are being cut off of very basic stuff… and then those governors are going to come running back," says Sen. Jay Rockefeller (D-W.Va.).

As such, the National Association of Public Hospitals and Health Systems (NAPH) is urging its public hospital members to continue lobbying for expansion in their states. "It's a little too early to see how it plays out, but I think states will definitely be considering that cost question as they make their decisions," says Beth Feldpush, NAPH's vice president for advocacy and policy.

In South Carolina, Gov. Nikki Haley (R) has said she will reject the ACA expansion. Nonetheless, the South Carolina Hospital Association continues to push for the provision. Last week, the group released a study indicating that the expansion would generate $3.3 billion in economic activity and $1.5 billion in additional income.

Similarly, hospital leaders in Alabama are urging Gov. Robert Bentley (R), who says the expansion is too costly for the state, to change his mind on the expansion. "It would appear that Alabama could greatly benefit from the additional federal funding with limited state investment," says Alabama Hospital Association's Rosemary Blackmon.

Efforts to push reluctant leaders to participate in the expansion may have made a difference in Nevada, where Gov. Brian Sandoval on Tuesday became the first Republican governor to say his state would opt into the expansion.

"Though I have never liked the Affordable Care Act because of the individual mandate it places on citizens, the increased burden on businesses and concerns about access to health care, the law has been upheld by the Supreme Court," Sandoval said in a statement, adding, "As such, I am forced to accept it as today’s reality and I have decided to expand Nevada’s Medicaid coverage."

Sandoval had previously said he was leaning against participation in the ACA provision, but several large health systems and hospital associations urged him to reconsider.

But not all hospital groups are on board with the ACA lobbying effort. Bucking the national trend, the Utah Hospital Association last month urged state leaders not to participate in the Medicaid expansion, saying "there are too many practical and political decisions to be made… to support the full Medicaid expansion at this time" (Daly, Modern Healthcare, 12/11 [subscription required]; Damon, Las Vegas Sun, 12/11; Vogel, Las Vegas Review-Journal, 11/15; Holleman, Columbia State, 12/8; Stephens, Birmingham News, 12/3).


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