By Marissa Evans, CQ Roll Call
September 30, 2016 -- As voters prepare to cast their ballot for the presidential election, in a few states the race for governor also could have major impacts on what's next for health care, especially for Medicaid expansion.
There are 12 gubernatorial races this election cycle, but only a modest number have a chance to flip parties, said Leighton Ku, a professor of health policy and management at the George Washington University Milken Institute School of Public Health.
The outcome of the presidential election also will affect what states can do in implementing the federal health law. Democratic nominee Hillary Clinton reiterated Wednesday in the New England Journal of Medicine that one of her top health care priorities is convincing governors in the 19 states that have not yet expanded eligibility for Medicaid, the federal-state program for the low-income, to do so. Republican presidential nominee Donald Trump has called for repealing the health law that allows states to broaden Medicaid eligibility and supports converting Medicaid from an entitlement program to a block grant program.
"The bigger question, particularly in situations where parties may change, may have to do with what happens at the national level," Ku said in an interview. "If Republicans do win the national election there could be big changes to the [federal health law]... States in all likelihood would face choices that are not currently available to them."
Voters in Delaware, Indiana, Missouri, Montana, New Hampshire, North Carolina, North Dakota, Oregon, Utah,Vermont, Washington, and West Virginia are considering gubernatorial candidates this election cycle.
Ku points to North Carolina's governor's race as one of the most important this election season. Republican Gov. Pat McCrory, the incumbent, is up against Roy Cooper, the Democratic challenger. McCrory has been embattled in the aftermath of signing off on the state legislature's so-called bathroom bill, which would have limited civil protections for transgender people and affect which restrooms they could use. He's also faced criticism over how he floated differing positions on Medicaid expansion during his term. Ku said since the state is considered to have more moderate voting patterns, it's a toss-up. "Who knows how it's going to go?" he said.
Medicaid expansion plans are something the gubernatorial candidates have had to weigh if they are running in one of the 19 states that did not expand eligibility. Under expansion, the federal health law allows states to expand Medicaid to individuals with incomes up to 138 percent of the poverty level. Starting in 2017, states will have to start chipping in 5 percent of the costs and by 2020, 10 percent of costs. Thirty-one states and the District of Columbia have taken up expansion.
Matt Salo, executive director for the National Association of State Medicaid Directors, said in an interview that for Medicaid expansion efforts in the last remaining states, the real question is what a governor may do on his or her own, such as through executive authority. Some may be willing to keep inherited expansion programs while others may block expansion. Salo points to examples in Louisiana, Kentucky, and Virginia, where new governors coming in under a party flip made decisions about Medicaid in complete opposition to their predecessors.
Louisiana Gov. John Bel Edwards, a Democrat, used his first executive order to expand the state's Medicaid program in July, while Virginia Gov. Terry McAuliffe has tried three times to convince his Republican legislature to open up eligibility, to no avail. Meanwhile, Kentucky Gov. Matt Bevin, a Republican, had said on the campaign trail he would dismantle the Medicaid expansion but walked back those comments so his administration could apply for a federal waiver that would change how the program works.
"[Bevin] wasn't a traditional Republican governor," Salo said. "He was really willing to shake some foundations and rattle some cages."
In the Utah gubernatorial race, incumbent GOP Gov. Gary R. Herbert continues to push for Medicaid expansion, which his Republican colleagues in the legislature have blocked so far. His Democratic opponent Mike Weinholtz says Herbert should do more to promote expansion.
As Vermont Gov. Peter Shumlin prepares to leave office, the Green Mountain State's gubernatorial race is also one to watch, said Trish Riley, executive director of the National Academy for State Health Policy, in an interview. Democrat Sue Minter and Republican Phil Scott are facing off in November.
Minter is aiming to take up Shumlin's efforts to implement universal health care in the state and improve the Vermont Health Connector, the state health insurance exchange website. Meanwhile, Scott says he, too, wants to fix the exchange website and further tackle the state's ongoing opioid abuse epidemic, including creating an Opioid Coordination Council to help oversee state agency efforts and programs related to helping provide services.
Vermont is "a little state but it's a laboratory nonetheless and that kind of activity is important," Riley said. "They have been leaders on so many fronts."
