Here’s something to keep an eye on: The overlap between Republicans who are balking at repeal-and-delay with Republicans from red states that have expanded Medicaid.
Numerous GOP Senators have, in some form or other, recently said they don’t want to vote to repeal the Affordable Care Act unless Republicans settle on a replacement first. Senator Tom Cotton said: “I think when we repeal Obamacare we need to have the solution in place moving forward.” Senator Rand Paul said: “I think it’s imperative that Republicans do a replacement simultaneous to repeal.” Senator Bill Cassidy also expressed reservations, pointing out that Donald Trump, too, had said he wants to see repeal and replace voted on “simultaneously.”
Senator Susan Collins today said that Republicans should have a detailed alternative blueprint of some kind in place before going forward with the repeal vote. Senator Lamar Alexander has also expressed serious reservations about repeal-and-delay with no guarantee of a replacement. So has Senator Bob Corker.
Senator Alexander’s reservations aren’t that surprising, because he’s the chair of the health and education committee, and probably wants (or so some Democrats believe) a big hand in a replacement bill. Senator Corker’s queasiness isn’t that surprising, either, because he prides himself on being a serious and deliberate lawmaker. Nor is Senator Collins’s reluctance, because she’s positioned herself as centrist-leaning in a bluish state.
But Senators Paul, Cotton, and Cassidy are surprising. They all come from deep red states, and aren’t known for exercising caution towards Obamacare. But all of them come from states that have expanded Medicaid.
The Medicaid expansion in Senator Paul’s Kentucky and in Senator Cotton’s Arkansas have helped lead to huge drops in the uninsured rate. Recent numbers from Gallup showed that the uninsured rate plummeted nearly 13 percentage points in both states — the highest in the nation. Senator Cassidy’s Louisiana only just expanded Medicaid, but more than 250,000 have signed up.
Or take West Virginia, which also expanded Medicaid. Recently Shelley Moore Capito, a GOP Senator from that state, said:
“I’m from a state that has an expanded Medicaid population that I am very concerned about….I don’t want to throw them off into the cold, and I don’t think that’s a strategy that I want to see. It’s too many people. That’s over 200,000 people in my state. So we need a transition. I think we’ll repeal and then we’ll work during the transition period for the replacement vehicle.”
It’s been sinking in lately among Republicans that replace will be a lot harder than they thought — and that repeal with no guarantee of replace later could unleash more problems than they expected during that “transition.” So keep an eye on Capito to see if her reservations grow stronger. By the way, Gallup found the uninsured rate dropped in that state by nearly 10 points.
All of this points to a dynamic that could impact the repeal-and-delay debate going forward: Republican officials in states that have expanded Medicaid might have a tougher time embracing repeal-with-no-guarantee-of-replace than we expect.
According to Larry Levitt of the Kaiser Family Foundation, senators from states that have expanded Medicaid might have an increased incentive to want a replacement plan up front. That’s because, if Republicans were to vote on repeal along with a replacement — one that, say, scraps the Medicaid expansion but replaces it with Medicaid block grants — those senators would be able to say, at least initially, that Medicaid money would continue flowing to their states, even after the ACA were repealed (and replaced).
This would be better than repeal with no immediate replacement, Levitt points out, because under the repeal-only scenario, they wouldn’t know if any of that money would be available later. “There’s no way for them to know how much of the losses from repeal that states and health care providers might be able to recoup under a replacement plan without seeing the details of that replacement plan,” Levitt says.
What’s more, these Senators likely know that if no replacement is voted on at the outset, any later replacement would likely be far less generous, because hard right conservatives would have more leverage to keep health spending down. As the Wall Street Journal editorial page recently warned, leaving replace until later would mean that conservatives, having already gotten the repeal they want, could now oppose any replacement “not designed by Ayn Rand.”
By my calculations, more than 20 GOP senators represent states that have expanded Medicaid. (The ones that have expanded Medicaid and have one or two GOP Senators are Alabama, Alaska, Arizona, Arkansas, Colorado, Indiana, Iowa, Kentucky, Louisiana, Montana, Nevada, North Dakota, Ohio, Pennsylvania, and West Virginia.) So if you see more senators balking at repeal-and-delay, and they come from those states, it won’t be all that surprising.
In the end, most of these Republicans probably will end up voting for a repeal-and-delay plan, since they may fear that the GOP base will pour forth fury if that glorious and cathartic repeal moment does not happen very quickly after Trump takes office. But the margin for error here is pretty slim. Only three GOP senators have to insist on a replacement plan for repeal-and-delay to hit the skids — which would mean Republicans would have to get serious about drawing up real consensus replacement legislation before repealing the ACA. Imagine that!
Update: This post originally stated, wrongly, that Maine has expanded Medicaid. I’ve corrected the error.