Ride or die.
Support The Bulwark.
  Join Now

The Odd Political Fight Over Medicaid Expansion in the Last 12 Holdout States

The parties jockey for position on how to add voters to Medicaid rolls—and claim credit for doing so.
July 22, 2021
Featured Image
People protest Trump administration policies that threaten the Affordable Care Act, Medicare and Medicaid, near the Wilshire Federal Building on January 25, 2017 in Los Angeles, California. / AFP / DAVID MCNEW (Photo credit should read DAVID MCNEW/AFP via Getty Images)

The fight over Medicaid expansion is about more than simply ensuring which policy gets the most people health insurance. It’s also—perhaps mostly—about ensuring which party gets the lion’s share of the kudos for making it happen.

As of now, twelve states have not yet expanded Medicaid, the public health care program for the poor, to include the people who fall into the “coverage gap”—that is, the people who don’t qualify for Medicaid in those states but also don’t qualify to enroll in health coverage under the Affordable Care Act. In March, President Joe Biden signed a bill that many observers hoped would entice the dozen states holding out.

The deal, which is still on the table, is this. The expansion would cost about $16.4 billion for those twelve states over two years, with the federal government picking up 90 to 95 percent of the cost, roughly $15 billion. This would mean that in Florida, for example, about 800,000 uninsured citizens would be covered, with the federal government paying about $1.5 billion each year and the state paying about $150 million annually.

Florida Governor Ron DeSantis’s response?

“The governor remains opposed to the expansion of Medicaid in Florida,” a DeSantis spokesman said in March.

Since then, Florida has, in fact, asked for more money for Medicaid. But DeSantis seems more interested in hiding the source of the money than obtaining it: Last week, Florida asked the feds for $1.1 billion for Medicaid to be taken from the American Rescue Plan funds. It’s pure politics, a suggestion that the profligate opposition is being wasteful.

Indeed, Aaron Bean, a Republican state senator, said Florida is being more careful and responsible than the federal government by asking for less than the expansion money would provide. “Some of the most expensive money out there is ‘free’ money from the federal government,” Bean said last week.

The timing of this request—and DeSantis’s relative silence in explaining the oddity of refusing government Medicaid expansion on one hand and asking for more Medicaid funding on the other—may be because COVID-19 cases are growing dramatically in the state.

Florida has emerged as a national hotspot, accounting for one in five new national cases last week. About 3,200 COVID patients were hospitalized in the state last week, an increase of 73 percent since June 14. And Florida now has the fourth-highest per-capita hospitalization rate in the United States, according to researchers at the University of South Florida.

The other issue is, not surprisingly, political. If DeSantis runs for re-election in 2022, Medicaid expansion could be an issue that has some importance in the state. Two Democrats challenging DeSantis—Rep Charlie Crist, a former governor, and Florida Agriculture Commissioner Nikki Fried—have already said they will push for Florida to expand Medicaid coverage to low-income childless adults.

While the political press has largely focused on the congressional bargaining over the proposed infrastructure bill and the fights over voting rights legislation, the implementation of Medicaid expansion is flying under the radar despite the fact it could well be an election year issue.

“By this time next year, by the time you guys run for re-election next year, you’ll be able to run on Medicaid expansion,” House Majority Whip James Clyburn recently told lawmakers in Alabama’s statehouse. “I think we [can] get that done—I know I’m gonna raise hell to get it done.”

Democrats are trying to set up programs and policies that let the poor, uninsured residents of those twelve states go directly through the federal government instead of their states to get Medicaid coverage. A bill that would do that was introduced last week by Sens. Raphael Warnock (D-Ga.), Tammy Baldwin (D-Wisc.), and Jon Ossoff (D-Ga.).

They are pretty blunt about what this would do:

The Medicaid Saves Lives Act would direct the Centers for Medicare & Medicaid Services (CMS) to create and standup a federal Medicaid look-alike program would provide the same full, essential benefits of Medicaid, and that is run and administered by CMS. . . . This would allow everyone in non-expansion states who is eligible for Medicaid coverage . . . [to get] full Medicaid benefits.

Rep. Lloyd Doggett (D-Texas) is introducing legislation that would allow local governments in Texas to expand Medicaid to more of their low-income residents by going directly to the federal government and bypassing the state. In Missouri, the state’s supreme court heard a case last week that would force the state legislature to expand Medicaid rolls by another 275,000 people or so.

Even in Wyoming, the legislature of which killed Medicaid expansion in committee earlier this year, has rethought things: A bill that would help 25,000 Wyoming residents who currently don’t qualify for Medicaid but can’t afford health insurance is getting a second look.

“We’re learning from other states how to formulate a solid Medicaid expansion for the people of the state. We’re learning from the mistakes of other [states] and learning what’s good and what’s bad,” said Wyoming State Sen. R.J. Kost.


The parties are desperate to get credit for expanding these policies because polling data suggests that Medicaid expansion is a solid win.

The pandemic has, perhaps unsurprisingly, put a renewed focus on health care. Meanwhile, unemployment led more people to Medicaid: In February 2020, 64 million adults were enrolled in Medicaid, a figure that grew to 74 million adults by January 2021.

Secondly, about one in five Americans are on Medicaid, and those enrolled are no longer concentrated in inner-city minority neighborhoods: suburban and rural enrollment figures have climbed.

Third, and perhaps most important, the polls say that the general population is in favor of expanding, not limiting, coverage. In North Carolina, for example, Republicans favor Medicaid expansion by a 64 to 20 percent margin, Democrats at 83 to 9 percent, and independents are at 76 to 19 percent. Other states show similar numbers, and that leads to the last point.

This issue, if played smartly by Democrats, could have an influence in the midterms. Five states in particular bear watching: Georgia, where Warnock is up for re-election in 2022; North Carolina, where GOP Sen. Richard Burr is retiring; Alabama, where GOP Sen. Richard Shelby is retiring; Wisconsin, where GOP Sen. Ron Johnson appears vulnerable; and Florida, where GOP Sen. Marco Rubio faces a re-election fight.

Warnock may have the closest race, hailing from a typically red state and being a member of the president’s party during that president’s first midterm, frequently a losing position. Hence his efforts to shore up any potential vote he can—and get credit for aiding his constituents in the process.

Georgia’s Republican leaders, Warnock said in a recent interview, are “complicating the situation by, first of all, digging in their heels for years, leaving us as one of only twelve states to refuse to expand Medicaid.” Warnock adds that work requirements that Georgia wants to include with Medicaid would not address the 500,000 citizens who would get coverage because of the expansion.

“I happen to think that health care is a human right and that when we provide Medicaid expansion to working-class people, to poor people, we enable them to work and to find work.”

Daniel McGraw

Daniel McGraw is a freelance writer and author in Lakewood, Ohio. Follow him on Twitter @danmcgraw1.