Health care may seem like it's faded into the background this midterm election cycle, but there is actually a lot at stake for many aspects of Obamacare.
In particular, the future of Medicaid expansion may be altered depending on which way the votes go.
Here’s a guide to what could change and why it matters:
First, an Explanation
Medicaid is a federally funded program that provides health care to low-income Americans. The Affordable Care Act expanded the program to cover more people, but a ruling by the Supreme Court allowed states to choose whether or not to implement that provision. To date, 23 states -- mostly conservative and Republican-controlled -- have elected not to expand.
Why Not Expand?
The main argument against expansion is that it’s too expensive and the federal government can’t continue supporting it long-term, said Scott Brunner, a senior analyst with the Kansas Health Institute and a former Kansas state Medicaid director.
“Many non-expansion states want to focus on improving quality of care before offering it to more people,” he added.
Those in favor of expansion believe it would provide health care to hundreds of thousands more people who currently can’t afford it, Brunner said, adding that a larger program might also stimulate the economy by creating health care-related jobs.
What’s at Stake?
While the focus of this election cycle has largely been on the Senate races and who will control Congress, it's probably the governor's races that will have the most influence on the direction of health care, said Dr. Benjamin Sommers, an assistant professor of health policy and economics at the Harvard School of Public Health.
“In states that have not yet expanded, there is still a significant debate going on,” he said. “Several very competitive governors’ elections include states that are on the fence about expansion.”
For example, Maine’s current governor, Paul LePage, has vetoed Medicaid expansion five times. If he loses today’s tight election to his Democratic opponent, Mike Michaud, Maine is more likely to go with expansion, Sommers said.
There is a similar scenario unfolding in Florida, Sommers added, but it is less clear in other battleground states whether a new governor alone would have enough authority to expand Medicaid without support from state government.
In Arkansas, a conservative state that has already opted for expansion, a reverse scenario is possible, Sommers said. Should the GOP candidate, Asa Hutchinson, win the close governor’s race, it isn’t clear whether or not he will vote to extend the expansion. Even if he does, the extension needs 75 percent of the votes of the state House and state Senate. If they gain control, several Republican candidates have pledged to end expansion.
The Bottom Line
Benefits are easier to add than take away, according to Sommers, so the Affordable Care Act is unlikely to go away anytime soon. But it is possible to reshape it and chip away at it at the state level.
“These elections can determine the direction of health care for the next few years,” Sommers said.