October 27, 2014; Idaho State Journal

At a meeting of Southeast Idaho doctors and state legislators, the big topic was whether to support the recommendation of the Idaho Medical Association to expand Medicaid coverage to persons with incomes up to 133 percent of the poverty level. The dynamics revealed in that Idaho meeting may be reflected in many states around the nation in the next year.

Democratic state representative Elaine Smith indicated that it was questionable whether the Idaho House of Representatives would even allow a hearing on the issue, much less turning Medicaid expansion into law.

Republican state senator John Tippets declared Idaho’s Medicaid situation “quite unique.” He acknowledged that there is a problem of the working poor who cannot afford health insurance without subsidies but are over the income limits to qualify, but he declined to support Medicaid expansion as an answer. While not explaining what he would do to fix the situation, Tippets said that 133 percent of the poverty level was, according to the Journal reporter, “way too high.”

Medicaid expansion is a contentious issue in Idaho’s gubernatorial election as well. Democratic challenger A.J. Balukoff favors expansion, but incumbent Republican C.L. “Butch” Otter is concerned about the sustainability of Medicaid.

Nonprofits concerned about healthcare coverage for the working poor have a lot of work ahead of them if they intend to make progress on Medicaid expansion in the South, Southwest, and West. For example, Republican gubernatorial candidate Greg Abbott supports the decision of Texas to reject federal moneys to expand Medicaid, arguing that he didn’t want “bureaucrats from Washington, D.C. dictating our healthcare policies in Texas.” His opponent, Democrat Wendy Davis, apparently favors the federally subsidized Medicaid expansion.

Alaska’s Republican governor Sean Parnell rejected the expansion of Medicaid to cover an additional 40,000 Alaskans, despite the offer of $3 billion in additional federal moneys, but his Democratic challenger completely disagrees. “I’ve always said, we will accept Medicaid expansion, and we will do it very quickly when we get into office,” Democrat Bill Walker said. “We’ll look at it when it’s no longer a hundred percent funded. But my goodness, when it’s a hundred percent funded, why would we not when it helps up to 40,000 Alaskans, creates up to 4,000 new jobs in Alaska, brings down overall health care? I just can’t say no.”

It isn’t always a question of Democrats versus Republicans. Ohio’s Republican governor, John Kasich, supported Medicaid expansion last year but was thwarted by the state legislature. Facing rejection, Kasich found a way of accepting federal moneys for a short-term Medicaid expansion, opening up coverage to some 400,000 Ohioans, but the deal needs to be reauthorized before it expires next June.

Republicans in the Ohio legislature are raising questions about the cost implications of longer-term Medicaid expansion, but they might want to examine costs beyond those that directly affect the state budget. For example, Ohio hospitals report that with expanded Medicaid coverage, they are seeing lower charity care costs and a sharp reduction in the numbers of people showing up looking for free healthcare treatment

Nonprofits do not and should not have to weigh in for or against specific candidates, but they should be educating candidates and the public about the broad picture of the costs of healthcare coverage for the poor and the working poor. That kind of public education advocacy, getting to the facts surrounding the need for Medicaid expansion, will help healthcare-prioritizing voters and the men and women they elect or re-elect on November 4th.—Rick Cohen