Why the GOP is embracing ACA's expansion—but not its exchanges

'Wonkblog' examines limited benefits of state-run marketplaces for Republican lawmakers

Topics: Access to Care, Quality, Performance Improvement, Appropriateness

February 25, 2013

Some of the GOP's most ardent opponents of the Affordable Care Act (ACA) are signing up to participate in the law's Medicaid expansion, but they remain committed in their rejection of state-run insurance exchanges.

Why Republican governors will expand Medicaid

Altogether, seven Republican governors have said they will participate in the Medicaid expansion, which was made voluntary by the Supreme Court's ruling on the ACA and will extend Medicaid eligibility to all state residents below 138% of the federal poverty limit.

Where does your state stand on the Medicaid expansion? Click to expand either a quick-to-scan graphic or an interactive graphic. (Note: interactive graphic may not be optimized for mobile devices.)

According to the New York Times, that "change of heart" comes after intense lobbying efforts by health care stakeholders, particularly hospitals—which agreed to the ACA's payment cuts under the assumption that they would gain many more patients newly covered by Medicaid.

Further, the Times notes that politics likely played a role in the seven states where GOP governors have decided to expand Medicaid. President Obama won all of those states, with the exception of Arizona and North Dakota, in last year's election. In addition, some of the governors are up for re-election in 2014.

Governors also have been lobbied by religious leaders, with Roman Catholic bishops of Salt Lake City and Little Rock, Ark., calling on state officials to expand Medicaid eligibility.

In addition, the Times credits the Obama administration's efforts to sway state officials by offering more flexibility. Gov. Rick Scott (R) agreed to expand Florida's Medicaid program the same day he received federal permission to shift nearly all of the state's beneficiaries into managed care plans.

Why Republican governors won't run their own exchanges

However, most Republican governors have continued to reject the idea of running their own health insurance exchanges.   

According to the Washington Post's "Wonkblog," the decision likely has to do with the large consequences for governors who do not expand Medicaid, compared with the limited benefit of setting up a complicated exchange. "Wonkblog" notes that a governor would be blamed if it were not run well, whereas the federal government will "swoop in" if a state decides not to run its own exchange (Goodnough/Pear, New York Times, 2/21; Kliff, "Wonkblog," Washington Post, 2/21).


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