The Washington PostDemocracy Dies in Darkness

The election might keep millions of people from getting health insurance

Maine Gov. Paul LePage (R), who was re-elected last night, has vetoed Medicaid expansion three times. (AP Photo/Robert F. Bukaty)

For Democrats, the lone bright spot in Tuesday's election was supposed to be potential Democratic victories in governors' races across the country, and with it, greater adoption of the Medicaid expansion under President Obama's health-care law.

Except that didn't happen. Fifteen of the 23 states that hadn't yet expanded Medicaid held gubernatorial elections last night, and it looks like only Alaska will elect a candidate who campaigned for the Medicaid expansion.

In Alaska, Independent candidate Bill Walker, who is holding a narrow lead over Gov. Sean Parnell (R), supports expanding Medicaid to an estimated 46,000 adults. There could also be a modest coverage gain in Pennsylvania, which already approved an alternative Medicaid expansion scheme under outgoing Gov. Tom Corbett. But expansion advocates there are urging Gov.-elect Tom Wolf (D) to scrap his predecessor's Medicaid plan in favor of the more traditional approach outlined by the Affordable Care Act.

You won't see new Republican governors in the traditionally blue states of Massachusetts and Maryland try to roll back Medicaid coverage. The one state where it seems like there's a real possibility of undoing a Medicaid expansion is in Arkansas, where three-quarters of the state legislature has to approve it every year. It was re-approved this past year, but not after another legislative fight.

The larger question now for the future of the Medicaid expansion — and Obama's health-care legacy — is whether the Republican wave will give the hold-out states further pause. In these states, an estimated 4.5 million people are shut out from coverage.

Even before last night's election, you saw a number of Republican governors from these states suggest they could explore expansion next year. Utah Gov. Mike Pence is already negotiating a plan with the Obama administration, and Utah Gov. Gary Herbert is expected to outline a formal plan this month. Republican governors in Tennessee, Wyoming, South Dakota and North Carolina have all also suggested they would consider Medicaid expansion plans in 2015.

Already, nine Republican governors have expanded their Medicaid programs, including a few who easily won re-election last night. And Medicaid expansion has support from hospitals, which hold considerable political clout and have a lot to lose without the infusion of federal funds from the expansion.

But any Republican governors who might consider the expansion next year could face a considerable obstacle: their own state legislatures. Last night's Republican wave also hit state legislatures, which became even more Republican, and the past two years of Obamacare politics show they're not afraid to battle Republican governors on this major piece of Obamacare.

"The people who elected them will be more conservative than the governor, and they will feel that the people who voted for them don't want to see any steps moving the ACA or the Medicaid expansion forward," said Robert Blendon, a professor of health policy and political analysis at the Harvard School of Public Health. The GOP state legislators, he said, will likely push governors to wait and see what changes to the law Congress will try to make now that Republicans control both chambers.

Last night's Republican victories won't slow down the Obama administration's push to bring more states into the Medicaid expansion. Just yesterday, Health and Human Services Secretary Sylvia Mathews Burwell asked governors to call her after the election to discuss opportunities for expansion.

But HHS may have to offer more flexibility to win over GOP-led states, Blendon said. For instance, instead of requiring states to extend Medicaid eligibility to 138 percent of the federal poverty level to receive enhanced expansion funds, Blendon said the administration could offer the same generous funding match but let states expand just to the federal poverty level. The move would likely upset Obamacare advocates, but could encourage more hold-out states to consider expansion.

"Does it have to be at the level it currently is, and does it have to be tied to the ACA the way it is?" Blendon said. "That's what I think the battle is going to be over the next year."