Medicaid has long been a political battleground. This week, as the records of both vice presidential candidates have been scrutinized, many have pointed out that Republican vice presidential candidate, as governor of Indiana, Mike Pence expanded Medicaid. Acclaimed health historian Naomi Rogers told The Politic that Medicaid expansion funding from the federal government was likely too promising for Pence to reject, regardless of conservative criticism of Medicaid as charity for the poor.
Medicaid expansion closes the “Medicaid gap.” Those making between 100% and 400% of the federal poverty level (FPL) qualify for a number of different government subsidies to offset the cost of healthcare or health coverage. These subsidies were created specifically for middle class Americans so they would not be unfairly burdened by health care spending.
Other citizens who are less well-off can qualify for Medicaid, which funds health services and health coverage. However, Medicaid eligibility is determined by each state, with the average cutoff for receiving benefits being 48% of the federal poverty level. This means that some Americans are eligible for neither Medicaid nor the middle class subsidies that kick in at 100% of the FPL, thus creating a gap of millions of Americans who cannot afford healthcare and are not eligible for government help.
At first, the Affordable Care Act required that states change their eligibility requirements so that anyone at 138% of the FPL was eligible, eliminating the gap. However, in National Federation of Independent Business v. Sebelius, the Supreme Court ruled that states should not have to expand Medicaid in order to continue to receive federal funds for Medicaid. This ruling lead to intense politicization of whether or not states would expand Medicaid.
Nineteen states, including Florida, Virginia, and Texas, have declined to expand Medicaid, for several reasons. Most cite cost. Federal subsidies to state governments promise to cover 100% of the cost of expansion for three years and 90% of the cost of expansion after 2020. Many state governors, however, feel they cannot stretch state budgets to cover the 10%.
Many states, particularly those with conservative governors, cite other reasons in addition to cost. As Rogers put it, “Medicaid has always been the orphan little sister of Medicare.” Many conservatives view Medicaid as an “entitlement” and want recipients to have “skin in the game” in order to receive it. These concerns have lead many state leaders to either refuse expansion or negotiate a more neoliberal expansion.
The latter option, expansion by conservative principles, is exactly what Pence did in Indiana. As Pence stated in a May 2014 speech, “Medicaid expansion proponents are satisfied with covering a vulnerable population with a program that is so deeply flawed. But I’m not. Fortunately, Hoosiers have found a better way.”
This “better way” means that Indiana adults who don’t pay premiums (a premium is a sum the insured person pays monthly or yearly to continue to have coverage) can have their coverage suspended for 6 months. Indiana expansion also requires Medicaid recipients to pay into “health care savings accounts” so that they have money saved with which to pay copays and premiums. About 345,000 Indiana adults are currently enrolled.
Rogers noted that Indiana’s expansion reflects a larger trend in the Republican Party. Conservative leaders may be able to adopt moderate or even “liberal” policies if an economic argument can be made in favor of said policy. As Rogers states, “A lot of governors found that they just couldn’t turn down Medicaid money for their states.” Even though medicaid expansion is viewed as a liberal idea, Pence was able to bring money into Indiana and provide many Hoosiers with healthcare without considerable criticism from conservatives because he presented it in terms of economics.
After all, Trump has changed positions on a number of social issues, such as LGBTQA rights and abortion access. Yet, he has support from many evangelicals because he is viewed as the “economics” candidate. We may find that Trump or conservative leaders who follow him may not stick to the conservative side of the “culture wars” if the issue can be framed in terms of putting money back in people’s pockets.