ATLANTA (AP) — Florida Gov. Rick Scott, who made a
fortune as a health care executive, long opposed President Barack
Obama’s remake of the health insurance market. After the Democratic
president won re-election, the Republican governor softened his tone. He
said he wanted to "have a conversation" with the administration about
implementing the 2010 law. With a federal deadline approaching, he also
said while Florida won’t set up the exchange for individuals to buy
private insurance policies, the feds can do it.
In New Jersey,
Gov. Chris Christie held his cards before saying he won’t set up his own
exchange, but he’s avoided absolute language and says he could change
his mind. He’s also leaving his options open to accept federal money to
expand Medicaid insurance for people who aren’t covered. The caveat,
Christie says, is whether Health Secretary Kathleen Sebelius can "answer
my questions" about its operations and expense.
Both Republican
governors face re-election in states that Obama won twice, Christie in
2013 and Scott in 2014. And both will encounter well-financed Democrats.
Their
apparent struggles on the issue, along with other postures by their GOP
colleagues elsewhere, suggest political uncertainty for Republicans as
the Affordable Care Act starts to go into effect two years after
clearing Congress without a single Republican vote. The risks also are
acute for governors in Democratic-leaning or swing-voting states or who
know their records will be parsed should they seek the presidency in
2016 or beyond.
"It’s a tough call for many Republican governors
who want to do the best thing for their state but don’t want to be seen
as advancing an overhaul that many Republicans continue to detest," said
Whit Ayers, a consultant in Virginia whose clients include Gov. Bill
Haslam of Tennessee, a Republican who didn’t announce his rejection of a
state exchange until days before Sebelius’s Dec. 14 deadline.
Indeed,
cracks keep growing in the near-unanimous Republican rejection of
Obama’s health care law that characterized the GOP’s political messaging
for the last two years. Five GOP-led states — Idaho, Mississippi,
Nevada, New Mexico, and Utah — are pressing ahead with state insurance
exchanges. Ongoing monitoring by The Associated Press shows that another
five Republican-led states are pursuing or seriously a partnership with
Washington to help run the new markets.
Democrats, meanwhile,
hope to use the law and Republican inflexibility to their advantage,
betting that more Americans will embrace the law once it expands
coverage. The calculus for voters, Democrats assume, will become more
about the policy and less about a polarizing president.
"It
shouldn’t be complicated at all," said John Anzalone, an Obama pollster
who assists Democrats in federal races across the country. Anzalone said
Republicans could use their own states-rights argument to justify
running exchanges. Instead, he said, "They are blinded by Obama-hatred
rather than seeing what’s good for their citizens."
Governors can
set up their own exchanges, partner with Sebelius’ agency or let the
federal government do it. The exchanges are set to open Jan. 1, 2014,
allowing individuals and businesses to shop online for individual
policies from private insurers. Low- and middle-income individuals will
get federal premium subsidies calculated on a sliding income scale.
Eighteen states plus Washington, DC, most led by Democrats, have
committed to opening their own exchanges.
The law also calls for
raising the income threshold for Medicaid eligibility to cover people
making up to 138 percent of the federal poverty line, or about $15,400 a
year for an individual. That could add more than 10
million people,
most of them childless adults, to the joint state-federal insurance
program for low-income and disabled Americans. Together, the exchanges
and the Medicaid expansion are expected to reduce the number of
uninsured by about 30 million people within the next decade.
A
Supreme Court ruling last summer made the Medicaid expansion voluntary,
rather than mandatory for states. At least eight governors, all of them
Republicans, have already said they have no plans to expand Medicaid.
The complexity is obvious.
National
exit polls from last month’s election showed that 49 percent of voters
wanted some or all of Obama’s signature legislative achievement rolled
back. Among self-identified independents, that number was 58 percent.
Among Republicans, it spiked to 81 percent. When asked about the role of
government, half of respondents said the notion that government is
doing too much fits their views more closely than the idea that
government should do more.
Before the election, a national AP-GfK
poll suggested that 63 percent of respondents preferred their states to
run insurance exchanges, almost double the 32 percent who wanted the
federal government to take that role. And the same electorate that tilts
toward repealing some or all of the new law clearly re-elected its
champion.
That’s not the most important consideration for
governors who face re-election in Republican states. Georgia’s Nathan
Deal and Alabama’s Robert Bentley, who also face 2014 campaigns,
initially set up advisory commissions to consider how to carry out the
health care law, but they’ve since jumped ship. But, unlike others, Deal
and Bentley aren’t eyeing national office.
Three Republicans who
are viewed as potential national candidates — Rick Perry of Texas, Nikki
Haley of South Carolina and Bobby Jindal of Louisiana — were
full-throated opponents. Jindal, the only one of the three who is
term-limited, is the incoming chairman of the Republican Governors
Association. In that role, he has co-signed more conciliatory letters to
Sebelius asking questions to flesh out how the designs might work.
Republican governors also are feeling quiet pressure from hospitals and other
providers.
Deal,
the Georgia governor, offers the typical argument for saying no: "We
can’t afford it." But the law envisions the new Medicaid coverage more
or less as a replacement of an existing financing situation that pays
hospitals to treat the uninsured. The law contemplates cuts in that
program, which already requires state seed money. The idea was that
expanding Medicaid coverage would reduce "uncompensated care" costs.
"Some
of those cuts were made with the expectation that Medicaid would be
expanded and that hospitals would be paid for portions of business that
we are not being paid for now," said Don Dalton of the North Carolina
Hospital Association.
Dalton’s Governor-elect, Republican Pat
McCrory, said as a candidate that he opposed Medicaid expansion. Dalton
said his industry is leaning on McCrory and legislative leaders, though
he commended "their deliberate approach." Similar efforts are underway
in South Carolina, Georgia, Missouri and elsewhere.
For Democrats,
Anzalone said the framing will be simpler: "You don’t want to take a
9-to-1 match? That’s a pretty easy investment. These governors who
aren’t expanding Medicaid, they’re basically giving taxpayer money to
the states that do."
Copyright 2012 The Associated Press.