E2 – Key Mid-Term Elections Driving Medicaid Expansion to Watch

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Avalere experts, Chris Sloan and Tiernan Meyer, discuss potential state and federal-level scenarios for Medicaid expansion.
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“If the governor has authority to expand Medicaid through executive order and does so immediately upon entering office, we could see an expansion as soon as late 2019.” Tiernan Meyer


Chris Sloan , Principal, Policy

Chris Sloan advises a number of clients, including pharmaceutical manufacturers, health plans, providers, and patient groups on key policy issues facing the healthcare industry.

Tiernan Meyer , Principal, Policy

Tiernan Meyer supports Avalere clients in analytic and strategic engagements focused on Medicaid, Medicare Part D, state health policy trends, and the impact of federal health reform.

This interview was originally published as a podcast. The audio is no longer available, but you can read the transcript below. For updates on our newly released content, visit our Insight Subscription page.

Explore Other Interviews in This Series

E1 – Impacts the Mid-Term Elections Could Have on Pre-Existing Conditions
E3 – Trends in Health Policy and the Mid-Term Elections Results


Chris: Hello, and welcome to the second in our three-part mid-term elections Avalere Podcasts series. My name is Chris Sloan. I’m a director in our federal and state policy group here at Avalere, and today we’re going to talk about another one of the big issues in the 2018 mid-term elections, and that is Medicaid expansion.

Joining me today is Tiernan Meyer, she is also a director in our federal and state policy group, and she is Avalere’s preeminent Medicaid expert. She can provide her thoughts about the implications of the midterm elections on Medicaid expansion and generally what the elections can mean for Medicaid. Thanks for being here, Tiernan.

Tiernan: Thanks, Chris.

Chris: Last week, we at Avalere released an analysis on Medicaid expansion and the mid-term elections. Can you walk me through the findings and the implications of what we found?

Tiernan: Certainly. The mid-term elections at the state level and particularly the governors elections could have a big impact on Medicaid expansion and driving some states towards expansion. Specifically, we know that 36 states are holding governors elections, and 14 of those states still have not expanded Medicaid under the Affordable Care Act. At least 6 of those 14 states are toss-up states where we think Democratic governors have a chance at winning the election. If those 6 states were to expand, per the analysis that Avalere conducted recently, we know that about 2.4 million individuals could gain Medicaid coverage, which is a significant increase in covered lives.

Another important consideration from the elections is the ballot initiatives. Specifically, we’re watching ballot referenda in 3 states, Idaho, Nebraska, and Utah, where voters will be voting on whether the state should expand Medicaid eligibility. As we’ve seen in the past, these ballot referenda do not always result in an instantaneous expansion. We’ve seen a lot of back and forth on this in Maine where voters voted to expand, and the governor has consistently been opposed. But, that absolutely conveys to state politicians that their constituency is interested in state Medicaid expansion, if nothing else.

Chris: Let’s imagine a Democratic candidate for governor wins the election in one of these states and has made Medicaid expansion a part of their platform. Is that it? Does the state then go ahead and expand Medicaid? What are the issues that have to be solved?

Tiernan: That’s a great question. Governors typically don’t have the power to expand unilaterally, but some of them do. For example, back in 2015, we saw that Governor Walker of Alaska expanded Medicaid very shortly after he came into office through an executive order, even against the wishes of legislature. We’ve seen that Kentucky followed a similar process of expanding Medicaid using governor authority. But, many states don’t allow governors that power. Because Medicaid expansion has budgetary implications, or because of other state laws that control governors’ power, that is not always possible. We really have seen that in some states where governors have pushed expansion but legislatures have been opposed, that’s held back the expansion.

Most recently, the forms that the Trump administration have been allowing through the waiver process, such as work requirements as a condition of eligibility, have expanded the reach of which legislatures will consider Medicaid expansion, though as we saw in Virginia’s decision to expand Medicaid this past May with the caveat that they are also looking towards a work requirement.

Chris: Let’s imagine you go past all those barriers and pass Medicaid expansion in some of these states. How long until it actually goes into effect and more people start enrolling in Medicaid?

Tiernan: If the governor has authority to expand through executive order and does so immediately upon entering office, we could see an expansion as soon as late 2019. That of course is in the simplest of cases where the expansion is just expanding eligibility for the current program. If a state wants to do something like using a work requirement or make any other substantive changes that would require a waiver approval from the federal government, 2020 at the earliest would be most realistic.

Chris: Now taking a step back and going up a level, are we looking at any federal implications for Medicaid from the mid-term elections?

Tiernan: What we’re most focused on at the federal level in terms of Medicaid is the potential for the rebirth of the repeal and replace discussion and discussions more broadly, whether inside or outside of that discussion, around changes to federal funding and looking at block grants or per capita caps since we know that there is support still among many federal legislators for this kind of reform. Given that the funding for Medicaid today is based on a federal match, moving to a block grant or per capita cap is a significant change that, as we’ve modeled in the past, could cause differences in state funding from where we see funding levels today. This could cause states to look again at their eligibility levels and whether or not expansion is viable for them as well as looking at what benefits look like in their state. That is a much longer shot option, but that’s, on the federal level, what we would be most watching in Medicaid.

Chris: Great, well we look forward to seeing what happens after the elections. That wraps up the second of our three Avalere mid-term elections podcasts. Next up, we will discuss the actual results of the election and some of the implications for health policy down the road. As always, watch for more updates and analysis from Avalere, and feel free to reach out to us with any questions. You’re listening to Avalere podcasts.


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