Expansion in the remaining 22 states
At this point, 22 states have yet to expand Medicaid under the ACA. And according to Joy Wilson of the National Conference of State Legislatures, the governors of those 22 states would need their legislatures to sign on to any expansion proposal. Although expansion is fully paid for by the federal government until 2017, when the federal contribution begins a gradual decline to covering 90% of the cost, legislatures must approve the receipt and expenditure of the funds. So if nothing else, "the governor has to get the legislature to go along because you've got to fund it," Wilson told me.
Last week, Republican Govs. Matt Mead of Wyoming and Bill Haslam of Tennessee discovered that this was easier said than done.
On Wednesday, a Tennessee Senate committee abruptly ended 21 months of work by voting down the deal Haslam had struck with HHS. Two days later, the full Senate and House in Wyoming voted down the plan Mead had negotiated.
Other governors changing their tune on expansion will likely run into the same problem. Of the 22 states that have not expanded Medicaid, only one does not have a statehouse controlled by the GOP. (That's Maine, where control of the legislature is split.)
So even if Alabama Gov. Robert Bentley (R) makes good on his pledge to reconsider Medicaid expansion, he would need to get his legislature on board. And newly elected Alaska Gov. Bill Walker (I) will need to get his proposal to expand Medicaid through a reluctant, GOP-controlled statehouse.
These are difficult tasks—but not necessarily impossible. GOP-controlled legislatures have approved expansion plans in the past. As Wilson points out, Michigan's Republican-led legislature voted down expansion proposals on more than one occasion before finding enough common ground to make it law and expand in 2014.
What about states that already expanded?
It's also worth noting that the debate on Medicaid isn't limited to states that have not yet expanded because CMS allows states that opted into the expansion to later opt out.
In Arkansas, where lawmakers pioneered the alternate expansion model, coverage has continued to be a high-profile issue and an important source of debate. Just last week, lawmakers reapproved funds for the expansion, which new Gov. Asa Hutchinson (R) has pledged to maintain until the state can find a more viable option.
However, Wilson notes that a state cannot move to discontinue expansion effective immediately. "There are provisions in place in the federal law that say you can't end it on the day they vote," Wilson says, explaining, "You have to give notice."