Republican lawmakers in half a dozen states are launching fresh efforts to expand Medicaid, the nation's health insurance program for the poor, as party holdouts who had blocked the expansion say they're now open to it because of Trump administration guidelines allowing states to impose new requirements that program recipients work to get benefits.
In Utah, a Republican legislator working with the GOP governor says he hopes to pass a Medicaid expansion plan with work requirements within the year. In Idaho, a conservative lawmaker who steadfastly opposed Medicaid expansion in the past says the new requirements make him more open to the idea. And in Wyoming, a Republican senator who previously opposed expansion - a key part of President Barack Obama's health-care law - says he's ready to take another look at fellow Republicans' expansion efforts in his state.
Moderate Republicans in North Carolina, Idaho and Kansas are similarly renewing calls to take up Medicaid expansion, although they face steeper climbs in convincing their conservative colleagues.
If successful, the efforts could make hundreds of thousands of Americans newly eligible for health coverage, while also opening the door to Medicaid changes that could kick some current beneficiaries out of the program and reduce its benefits to recipients - broadening the program's reach into red states but with a decidedly conservative bent.
"All of a sudden, we're seeing some flexibility that allows us to do it our way, and that gives it a much better chance," said Wyoming state Sen. Ogden Driskill, a Republican who helped defeat Medicaid expansion in a close vote in 2015. "Without the heavy hand of the government forcing it down our throats, many of us will take a much deeper look at it."
The Trump administration earlier this month said states could apply to add work requirements to their state Medicaid programs, a first in the program's history. Ten states have already filed requests for such waivers, and the Trump administration has approved a Kentucky plan to add work requirements and premiums to its program.
The new Trump administration rules may also shake up the balance of power in state-level struggles over Medicaid expansion. Thirty-two states and Washington, D.C., have expanded Medicaid since the Affordable Care Act was enacted, giving health care to approximately 13 million additional people. (Maine voters approved a Medicaid expansion in a November ballot referendum, but it has not yet taken effect.)
The other 17 states are overwhelmingly GOP-dominated. In many, Democrats and some moderate Republicans repeatedly have attempted expansions, hoping to take advantage of federal funding available to provide health insurance for low-income patients. But they've seen their efforts thwarted by conservative lawmakers and governors, who argue that expansion would give health care to "able-bodied" Americans and explode state budgets.
Now, moderate Republicans hope to win over their conservative colleagues by packaging the expansion with work requirements or other limits on who is eligible for the program, under what circumstances and for how long.
Their chances of success vary widely depending on the state. In Utah, a Republican lawmaker who has opposed a more generous Medicaid expansion is working with a supportive governor and supportive leaders in the state's House and Senate on a version of it that would include work requirements.
Under the new rules, "we think that there may be a window of opportunity to revisit the idea of Medicaid expansion," Utah Gov. Gary Herbert, R, said in a statement to The Washington Post. Utah has 46,000 residents who could gain insurance under Medicaid expansion, according to the Kaiser Family Foundation, although the plans being discussed would probably cover a lower number.
Utah state Rep. Robert Spendlove, R, is spearheading a plan to expand Medicaid that would impose work requirements on some residents. Spendlove has wanted to craft this kind of package for years, but says he was told by Obama administration officials that the federal government would stop an expansion proposal that included work requirements.
To make the changes, states would need a waiver from the Trump administration's Department of Health and Human Services. For the first time, that option is available.
"I'm not Captain Ahab; I didn't see the point in pursuing an expansion bill that wasn't going to get approved," said Utah's Spendlove, adding that he is working with leadership in the state House and Senate on his proposal. "The importance of the Trump administration's willingness to give states flexibility to manage their programs can't be overstated."
Kansas in 2017 came within three votes of overriding outgoing GOP Gov. Sam Brownback's veto of a Medicaid expansion plan. Moderate Republicans are hoping work requirements would be enough to get the proposal over the finish line, but it's unclear if Brownback's replacement, Republican Jeff Colyer, would support a deal. "This gives us a great opportunity and something to run with," said Republican state Rep. Barbara Bollier, who has tried pushing conservatives in her state to accept Medicaid expansion.
The Affordable Care Act law sought to extend Medicaid to every American living on less than 133 percent of the federal poverty line, implementing a national standard to replace a system in which each state sets its own eligibility threshold. But the Supreme Court struck down that portion of the law, allowing states to decline the extension.
As a result, millions of residents in holdout states fall in the "Medicaid gap." Their incomes are too high to qualify for Medicaid, but they make too little to meet the minimum threshold for federal insurance subsidies to help them buy private health insurance policies on Obamacare's exchanges.
"It was a huge roadblock that we did not have the ability to get a waiver for work requirements," said Idaho state Sen. Marv Hagedorn, R, who said he will be talking with colleagues about potential vehicles for expansion. "I'm very optimistic now that the administration has done a 180 on that. We'll see if we can make something happen for people we have in the gap population."
In states where lawmakers have repeatedly battled over Medicaid, the proposals face an uphill climb.
In Virginia, where Democrats picked up more than a dozen seats in elections last fall and Republicans only hold a two-seat advantage in the state House and Senate, a moderate Republican is seeking a bipartisan deal to pair expansion with work requirements. But a spokesman for new Virginia Gov. Ralph Northam, a Democrat, said the governor does not support work requirements and that "very initial" conversations are ongoing with GOP lawmakers about Medicaid expansion in 2018.
The odds may be even longer in North Carolina, where moderates are pushing to pair expansion with work requirements but even proponents are skeptical the legislature's powerful conservative bloc can be won over. Roy Cooper, the state's Democratic governor, is "pleased that there is some movement" on Medicaid expansion, said spokeswoman Sadie Weiner, though she added that Cooper has concerns about work requirements.
Many Democrats share those concerns. While they've long sought expansion, the deals being pushed would require them to accept rules they say will cost thousands of poor Americans their insurance. Republican-led states ranging from Arizona to Indiana are asking for a range of changes aimed at reducing the generosity of the program, including new fees for emergency-room use, premium payments for the poor, and the loss of coverage for those who miss payments.
"Expanding does create the opportunity to cover more people, but if it's done with things like work requirements, premiums and other similar policies we know reduce coverage, the gains won't be as large," said MaryBeth Musumeci, a Medicaid expert at Kaiser.
In other states, expanding Medicaid remains a non-starter for conservatives. Georgia Gov. Nathan Deal and South Dakota Gov. Dennis Daugaard, both Republicans, said through spokesmen that Medicaid expansion would not be on the table in their states.
"There will be state legislators who were previously skeptical of Medicaid expansion, but who now think they can get behind it," said Akash Chougule, director of Americans for Prosperity, a right-leaning political advocacy group affiliated with the Koch brothers. "But for us, the fact remains that expanding eligibility will massively increase spending costs. That might be blunted a little bit by a work requirement, but we will continue to resist those calls to expand."