The Washington PostDemocracy Dies in Darkness
The Health 202

A newsletter briefing on the health-care policy debate in Washington.

Ten states still spurn Medicaid expansion — and they're unlikely to budge soon

The Health 202

A newsletter briefing on the health-care policy debate in Washington.

Hello, good morning. ICYMI, The Post put out a nine-story project examining the rise of the AR-15, a semiautomatic weapon that has polarized the country. 

Reading this online? Sign up for The Health 202 to get scoops and sharp analysis in your inbox each morning. 

Today’s edition: What to watch when the nation’s top federal health official, Xavier Becerra, testifies again on Capitol Hill today. Georgia’s Supreme Court will hear oral arguments in a case on the state’s ban on abortion after fetal cardiac activity is detected. But first … 

North Carolina is joining the Medicaid expansion club. That leaves 10 states still outside.

North Carolina is poised to become the 40th state to expand Medicaid. 

Yesterday afternoon, Gov. Roy Cooper (D) signed legislation crafted by the state’s two Republican leaders, an unlikely deal that puts an end to an over-a-decade-long political battle. 

But North Carolina may be the last of the Medicaid expansion holdout states to reverse course for a while. Supporters of extending the safety net coverage to hundreds of thousands more low-income adults have repeatedly run into Republican resistance in the 10 states that have long refused the Obamacare program — and another victory isn’t imminent. 

“Now we’re down to some of the hardest states to get expansion through,” said Frederick Isasi, the executive director of Families USA, a left-leaning consumer health lobby, though he expressed confidence the remaining states would eventually budge. 

Over the years, some steadfast GOP opposition to Medicaid expansion has softened, such as in North Carolina. The 2010 Affordable Care Act required states to extend the safety net program up to 138 percent of the federal poverty level, but the Supreme Court made doing so voluntary. 

More from Cooper:

The ballot measures

Since 2017, advocates have put expanding Medicaid directly to voters in seven conservative-leaning states. They argued it would bring federal taxpayer dollars back to their state and help struggling rural hospitals — and the ballot measures passed in every instance. 

But that strategy may be almost exhausted. Three of the holdout states have had citizen-led ballot measure processes — Florida, Wyoming and Mississippi — but at the moment, that path only appears viable in one state.

That’s Florida, where Medicaid advocates have their eye on fall 2026. Florida Decides Healthcare, a political committee supporting expansion, estimates it’ll cost roughly $10 million just to gather enough signatures to get the measure on the ballot, according to Jake Flaherty, the group’s campaign manager. 

  • Even if that happens in a few years, there’s another hurdle. An amendment to the constitution must garner the support of 60 percent of voters. Only once — in Idaho — has that happened for Medicaid expansion. 

The prospects are dim in the near future for the other two states. Wyoming advocates don’t believe they can use the ballot measure process to expand Medicaid, citing a mandate that an initiative not “make appropriations.” The next best chance is likely 2025, when the state legislature convenes again for a general session, according to Nate Martin, the executive director of Better Wyoming.

And in Mississippi, advocates filed paperwork to launch an expansion campaign in 2021. But it had to disband a month later when the state Supreme Court nullified the ballot measure process until state lawmakers fixed it, which the legislature failed to do this year, the Clarion Ledger reported.

Other states

North Carolina is the first state to expand Medicaid through the legislature since Virginia in 2018. And it’s still not finalized: The expansion is tied to the state passing a new budget, which is expected to occur over the summer. 

Other states that haven’t expanded include Alabama, Georgia, Kansas, South Carolina, Tennessee, Texas and Wisconsin. Republicans opposing expansion have often cited fiscal concerns with the policy, which supporters push back against and have pointed to extra two-year incentives signed into law in 2021.  

Several advocates said they’re watching Alabama closely, and that Gov. Kay Ivey (R) has the power to expand Medicaid without the GOP-led legislature’s sign-off. Last week, a House committee held an educational meeting on addressing the state’s coverage gap, the Alabama Reflector reported. In a statement to The Health 202, spokesperson Gina Maiola wrote that “the governor’s concern remains how the state would pay for it long-term.”

And in Kansas, Democratic Gov. Laura Kelly has been pushing the issue for years. But it’s an uphill battle to get it passed this year amid some Republican opposition, Will Lawrence, her chief of staff, acknowledged in an interview. Lawrence said he believes if a deal can be reached with the House speaker at some point, then the Senate may come along.

  • “We'll continue to push those conversations,” Lawrence said. He added: “If it doesn't happen this session, then we'll be working over the summer and fall, like we did a few years ago, and we'll come back with a strong push in January of next year.”

On the Hill

Three things to watch during the House Ways and Means hearing with Becerra

On tap today: Health and Human Services Secretary Xavier Becerra will defend President Biden’s fiscal 2024 budget before the Republican-controlled House Ways and Means Committee this afternoon. Becerra will also appear before a House Appropriations subcommittee at 10 a.m.

What to expect: There are three main proposals in the president’s budget request that panel Chair Jason Smith (R-Mo.) and other Republicans on the panel plan to grill Becerra on during the hearing, according to people familiar with the matter. Those include:

While Becerra was summoned to Capitol Hill to discuss the president’s budget, lawmakers could use the opportunity to quiz him on a variety of health policies. He’s likely to face criticism and tough questions from Republicans on the federal health department’s final rule addressing the Affordable Care Act’s “family glitch,” its implementation of surprise billing protections and its strategy to combat illicit fentanyl trafficking, people familiar with the matter said.

What we’re watching tomorrow: Becerra will testify in front of the House Energy and Commerce health subcommittee at 10 a.m. Wednesday.

New this a.m.: Cassidy, Merkley target Medicare Advantage coding in new bill

Sens. Bill Cassidy (R-La.) and Jeff Merkley (D-Ore.) are introducing a bill today that would change the way Medicare Advantage plans assess patients’ health risks with the aim of reducing overpayments for care.

If signed into law, the No Unnecessary Payments, Coding Or Diagnoses for the Elderly (Upcode) Act would develop a risk-adjustment model that uses two years of diagnostic data instead of just one year; limit the ability for insurers to use old or unrelated medical conditions, which could inflate the cost of care; and close the gap between how a patient is assessed under traditional Medicare and Medicare Advantage.

Key context: Republicans are historically champions of the Medicare Advantage program and have been hesitant to make changes to it in the past. Unlike traditional Medicare, Medicare Advantage plans are paid a fixed amount per enrollee that includes a formula called a “risk score” — which pays higher rates for sicker patients and less for those in good health. Because of this, critics allege that Medicare Advantage plans have a financial incentive to overstate the severity of their beneficiaries' medical conditions so that they can receive higher payments.


On tap today: Georgia’s Supreme Court will hear oral arguments in a case on the state’s abortion ban after fetal cardiac activity is detected at roughly six weeks of pregnancy.

Last November, Fulton County Superior Court Judge Robert McBurney ruled that the state’s ban on the procedure was unconstitutional because it was passed before the Supreme Court overturned Roe v. Wade. His decision immediately halted enforcement of the law, but one week later, the high court reinstated the ban while it considered an appeal of McBurney’s ruling brought by the state’s Republican attorney general.

In other health news

  • Trial proceedings will kick off today in a lawsuit brought by the state of Minnesota against Juul Labs, marking the first time any of the thousands of cases against the e-cigarette maker over its alleged marketing to minors is going to play out in a courtroom, per the Associated Press’s Steve Karnowski.
  • The Food and Drug Administration will convene a meeting of its independent advisers to review a personalized cell therapy for ALS that the agency had previously refused to consider. A date has not yet been set, Stat’s Adam Feuerstein reports.
  • Ohio’s Republican attorney general filed a lawsuit yesterday accusing three pharmacy benefit managers of sharing drug-pricing information to gain leverage during negotiations with drugmakers, Jared S. Hopkins writes in the Wall Street Journal.
  • The Federal Trade Commission’s proposal to ban noncompete clauses in employment contracts is drawing fierce criticism from some hospitals and private equity-backed medical groups, who argue that the move could drive up the cost of care for patients because administrators would have to pay physicians more to keep them, Harris Meyer reports for Kaiser Health News.

Health reads

The Blast Effect (By N. Kirkpatrick, Atthar Mirza and Manuel Canales | The Washington Post)

Fentanyl Fuels Surge in Deaths Among Those Who Are Homeless (By Jon Kamp and Dan Frosch | The Wall Street Journal)

A half century after Prozac, a new generation of depression drugs is bringing hope to a long-stagnant field (By Benedict Carey | Stat)

Sugar rush

Thanks for reading! See y'all tomorrow.