Where the States stand on Obamacare’s Medical Expansion

NOT PARTICIPATING (14 states)

• Alabama*: Gov. Robert Bentley (R) on Nov. 13 announced that Alabama will not participate in the Medicaid expansion “because we simply cannot afford it” (Gadsden Times, 11/13; Lyman, Montgomery Advertiser, 11/13).
• Georgia*: Gov. Nathan Deal (R) in an Atlanta Journal-Constitution/Politico/11 Alive interview on Aug. 28 said, “No, I do not have any intentions of expanding Medicaid,” adding, “I think that is something our state cannot afford.” When asked about the insurance exchanges, Deal said “we do have a time frame for making the decision on that I think, especially on the exchanges,” adding that “we have just a few days after the election in order to make a final determination on that” (Wingfield, “Kyle Wingfield,” Atlanta Journal-Constitution, 8/28).
• Idaho*: Gov. C.L. Otter (R) in his 2013 State of the State address delivered on Jan. 7 said that while “there is broad agreement that the existing Medicaid program is broken,” the state “face[s] no immediate federal deadline” to address the situation. He added, “We have time to do this right … [s]o I’m seeking no expansion of” the program. Otter said he’s instructed the state Health and Welfare director to “flesh out a plan” that focuses on potential costs, savings and economic impact, which he plans to introduce in 2014 (Ritter Saunders, Boise State Public Radio, 1/7; Young, Huffington Post, 1/7; Petcash, KTVB, 1/7).
• Iowa*: Gov. Terry Branstad (R) on Feb. 23 said that he has informed HHS Secretary Kathleen Sebelius that he will not expand Medicaid in Iowa because of concerns that the expansion “will either collapse or the burden will be pushed onto the states in a very significant way.” Instead, Branstad pressed Sebelius for a federal waiver to continue IowaCare, a health care program that provides limited benefits to 70,000 low-income state residents (AP/Modern Healthcare, 2/24).
• Louisiana*: Gov. Bobby Jindal (R) in an NBC “Meet the Press” interview on July 1 said, “Every governor’s got two critical decisions to make. One is do we set up these exchanges? And, secondly, do we expand Medicaid? And, no, in Louisiana, we’re not doing either one of those things.” However, state Sen. Karen Carter Peterson (D) and other Democratic leaders after the Nov. 6 election urged Jindal to reconsider his opposition or the state will not be forced to accept a “one-size-fits-all” plan, CBC News “Money Watch” reports (Barrow, New Orleans Times-Picayune, 7/2; “Money Watch,” CBS News, 11/9).
• Maine*: Gov. Paul LePage (R) on Nov. 16 said that Maine will not participate in the Medicaid expansion. He called the expansion and the state-based insurance exchanges a “degradation of our nation’s premier health care system” (Mistler, Kennebec Journal, 11/16).
• Mississippi*: Gov. Phil Bryant (R) on Nov. 7 said Mississippi will not participate in the Medicaid expansion, reiterating previous statements that he had made about the ACA provision (Pender/Hall, Jackson Clarion-Ledger, 11/7).
• North Carolina: Gov. Pat McCrory (R) on Feb. 12 announced that his state will not expand Medicaid or establish its own health insurance marketplace under the Affordable Care Act. McCrory said state officials conducted a comprehensive analysis to determine the advantages and disadvantages of expanding Medicaid and the right type of exchange option in the state, and concluded that it is “abundantly clear that North Carolina is not ready to expand the Medicaid system and that we should utilize a federal exchange.” He said the review included discussions with other governors, White House officials, health care providers, and leaders in the state Legislature (AP/Myrtle Beach Sun News, 2/12; Binker/Burns, “@NCCapitol,” WRAL, 2/12; Cornatzer, Raleigh News & Observer, 2/12).
• Oklahoma: Gov. Mary Fallin (R) on Nov. 19 said Oklahoma will not participate in the Medicaid expansion. “Oklahoma will not be participating in the Obama Administration’s proposed expansion of Medicaid,” she said in a statement. She noted that the program would cost the state as much as $475 million over the next eight years (Greene, Tulsa World, 11/19).
• Pennsylvania*: Gov. Tom Corbett (R) on Feb. 5 sent a letter to HHS saying he “cannot recommend a dramatic Medicaid expansion” in Pennsylvania because “it would be financially unsustainable for Pennsylvania taxpayers.” He noted that the expansion would necessitate “a large tax increase on Pennsylvania families” (Tolland, Pittsburgh Post-Gazette, 2/5).
• South Carolina*: Gov. Nikki Haley (R) on July 1 announced via Facebook that South Carolina “will NOT expand Medicaid, or participate in any health exchanges.” The state Legislature is expected to make a decision on the Medicaid expansion during the 2013 session (Gov. Haley Facebook page, 7/1; Holleman, Columbia State, 11/9).
• South Dakota: Gov. Dennis Daugaard (R) in his annual budget address on Dec. 4 said he does not plan to participate in the Medicaid expansion. “I really think it would be premature to expand this year,” he said, adding that he hoped for more flexibility for the state program (Montgomery, Sioux Falls Argus Leader, 12/4).
• Texas*: Gov. Rick Perry (R) in a statement on July 9 said, “If anyone was in doubt, we in Texas have no intention to implement so-called state exchanges or to expand Medicaid under ObamaCare.” Perry also sent a letter to HHS Secretary Kathleen Sebelius on July 9 asserting this position. The Dallas Morning News reported that on Nov. 8, Perry reiterated his opposition to the expansion, saying, “Nothing changes from our perspective” (Office of Gov. Perry release, 7/9; Gov. Perry letter, 7/9; Garrett, Dallas Morning News, 11/11).
• Wisconsin*: Gov. Scott Walker (R) on Feb. 13 announced his rejection of the Medicaid expansion. He proposed an alternative plan that would expand coverage to low-income state residents through private health care exchanges (Spicuzza, Wisconsin State Journal, 2/13).

LEANING TOWARD NOT PARTICIPATING (2 states)

• Nebraska*: Gov. Dave Heineman (R) in a statement on his website on June 28 said, “As I have said repeatedly, if this unfunded Medicaid expansion is implemented, state aid to education and funding for the University of Nebraska will be cut or taxes will be increased. If some state senators want to increase taxes or cut education funding, I will oppose them.” Heineman on July 11 sent a letter to state lawmakers saying the state could not afford the expansion, but he stopped short of saying that the state will not participate in the expansion, according to Reuters (Office of Gov. Heineman release, 6/28; Wisniewski, Reuters, 7/11).
• Wyoming*: Gov. Matt Mead (R) on Nov. 30 recommended that Wyoming not participate in the Medicaid expansion, but added that his position could change in the future and urged “everyone to keep an open mind on this.” The state legislature will make the final decision on whether to expand the program, the AP/Jackson Hole Daily reports (Brown, Wyoming Tribune Eagle, 12/1; Graham, AP/Jackson Hole Daily, 12/1).

LEANING TOWARD PARTICIPATING (4 states)

• Kentucky: Gov. Steve Beshear (D) when asked about the expansion in July said, “If there is a way that we can afford that will get more coverage for more Kentuckians, I’m for it.” However, state lawmakers are putting pressure on Beshear to reject the expansion (Office of Gov. Beshear release, 6/28; AP/Evansville Courier & Press, 6/28; AP/Evansville Courier & Press, 7/17; Autry, WYU, 7/5; Cross, Louisville Courier-Journal, 6/29).
• New York: Gov. Andrew Cuomo (D) in a statement on his website on June 28 said he was “pleased the Supreme Court upheld the [ACA]” and looks forward “to continuing to work together with the Obama administration to ensure accessible, quality care for all New Yorkers.” On July 26, Danielle Holahan—project director for New York’s health insurance exchange planning—said the state “largely meet[s] the federal required Medicaid levels already.” Although Cuomo’s office has not officially announced a decision, the Associated Press reported on Nov. 13 that New York will expand Medicaid (Office Gov. Cuomo release, 6/28; Grant, North Country Public Radio, 7/27; Delli Santi/Mulvihill, AP/San Francisco Chronicle, 11/13).
• Oregon: Gov. John Kitzhaber (D) said on June 28 that he is confident that the Oregon Legislature will approve a state Medicaid decision. In an interview with the Oregonian just hours after the Supreme Court issued its ruling on the ACA, Kitzhaber said, “We’ll make a decision on whether or not to expand the Medicaid program really based on, I think, the resources we have available in the general fund for that purpose going forward” (Budnick, Oregonian, 6/28).
• Virginia: The House of Delegates and Senate on Feb. 23 amended the state budget to include the ability to expand the state’s Medicaid program. According to the Richmond Times-Dispatch, the move gives “a green light” to talks between state and federal officials over flexibility in the Medicaid program. Although Medicaid expansion supporters have hailed the legislative action as a victory, Gov. Bob McDonnell (R) on Feb. 23 said, “As long as I’m governor, there’s not going to be any Medicaid expansion unless there is sustainable, long-lasting, cost-saving reforms” (Martz, Richmond Times-Dispatch, 2/24).

PARTICIPATING (24 states and the District of Columbia)

• Arizona*: Gov. Jan Brewer (R) in her 2013 State of the State speech, delivered on Jan. 14, announced that Arizona will participate in the Medicaid expansion, which would extend health care services to an estimated 300,000 more state residents. Brewer noted that the expansion plan will “include a circuit-breaker that automatically” would reduce enrollment if federal reimbursement rates decrease. Brewer was expected to offer further details of the plan in her budget proposal, which is subject to approval by the Republican-controlled Legislature (Christie, AP/Sacramento Bee, 1/14; Sanders/Wingett Sanchez, Arizona Republic, 1/14; Fischer, Sierra Vista Herald, 1/14; Safier, Tucson Citizen, 1/14).
• Arkansas: Gov. Mike Beebe (D) on Sept. 11 said he planned to participate in the Medicaid expansion, the Associated Press reports. According to the AP, Beebe agreed to participate in the expansion after officials assured him the state could opt out later if it faces a financial crunch. Beebe said, “I’m for it. I think it’s good for our people because it’s helping folks that don’t have insurance now that are working their tails off. They’re not sitting on a couch somewhere asking for something” (Brantley, Arkansas Times, 9/11).
• California: Gov. Jerry Brown (D) in a statement on June 28 said the Supreme Court’s ruling “removes the last roadblock to fulfilling President Obama’s historic plan to bring health care to millions of uninsured citizens.” California got a head start on expanding its Medicaid program in November 2010 with its “Bridge to Reform” program, which aimed to bring at least two million uninsured Californians into Medicaid (Office of Gov. Brown release, 6/28; DeBord, “KPCC News,” KPCC, 6/28).
• Colorado*: Gov. John Hickenlooper (D) on Jan. 3 announced that his state will participate in the expansion. In a news release, his office said the move would extend Medicaid coverage to about 160,000 low-income residents and save Colorado an estimated $280 million over 10 years without affecting the state’s general fund (Stokols, KDVR, 1/3; Wyatt, AP/Denver Post, 1/3).
• Connecticut: Gov. Dannel Malloy (D) was among the first governors to sign up for the Medicaid expansion after the ACA was enacted in March 2010. Soon after the Supreme Court ruling on June 28, Malloy said “it’s great … [and a] very important decision for the people of Connecticut. 500,000 people would have lost coverage if Republicans had their way” (Davis, WTNH, 6/28).
• Delaware: Gov. Jack Markell (D) in a statement on June 28 said, “The Supreme Court’s ruling enables Delaware to continue to implement provisions of the Patient Protection and Affordable Care Act to provide access to health care benefits for Delawareans.” He added, “On the Medicaid front, Delaware already voluntarily expanded the state’s Medicaid coverage program in 1996 to cover many Delawareans not previously covered” (Office of Gov. Markell release, 6/28).
• District of Columbia: D.C. Mayor Vincent Gray (D) in a statement on June 28 said, “The District is not at risk of losing any Medicaid funding as a result of this ruling, because District officials have already begun implementation of the ACA’s Medicaid-expansion provisions and will continue to implement the expansion” (Executive Office of the Mayor release, 6/28).
• Florida*: Gov. Rick Scott (R) on Feb. 20 announced that the state will participate in the ACA’s Medicaid expansion, citing HHS’s conditional support for a waiver to shift most of the state’s Medicaid beneficiaries into a managed-care program. However, Scott said that Florida would only participate in the expansion for three years before reevaluating the decision. Supporters of the ACA heralded Florida’s shift as a major reversal; Scott mounted his successful campaign for governor in 2010, in part, by being one of the nation’s foremost critics of President Obama’s planned health reforms (Kennedy/Fineout, Associated Press, 2/20; Office of Gov. Scott release, 2/20).
• Hawaii: Gov. Neil Abercrombie (D) in a statement on June 28 welcomed the Supreme Court’s ruling and said the ACA “is our ally” in the effort to “support a health care system that ensures high quality, safety and sustainable costs.” Pat McManaman, director of the state Department of Human Services, said Hawaii’s Medicaid eligibility requirements in July would fall in line with the law’ guidelines, meaning an additional 24,000 people will be eligible for the program by 2014 (Office of Gov. Abercrombie release, 6/28; Garcia, AP/CBS News, 6/29).
• Illinois: Gov. Pat Quinn (D) on June 28 praised the court’s decision and said he “will continue to work with President Obama to help working families get the healthcare coverage they need,” including expanding Medicaid (Office of the Governor release, 6/28; Thomason, Rock River Times, 7/3; Ehley, Fiscal Times, 8/20).
• Maryland: Gov. Martin O’Malley (D) in a statement on June 28 said the Supreme Court’s decision “gives considerable momentum to our health care reform efforts here in Maryland,” adding that the state will move forward to implement the overhaul (Office of the Governor release, 6/28).
• Massachusetts: Gov. Deval Patrick (D) in late June said Massachusetts is “an early expansion state as you know and we’re expecting further resources from the federal government to sustain the experiment here in Massachusetts.” Patrick called the ruling “good news for us” (Walker, YNN, 6/28).
• Michigan*: Gov. Rick Snyder (R), in a statement released on Feb. 6, announced that his fiscal year 2014 budget proposal includes a plan to expand the state’s Medicaid program under the Affordable Care Act. The plan would extend Medicaid benefits to about 320,000 eligible residents. Snyder said the plan contains safeguards that will ensure the financial stability of the program and protect against changes in the government’s financial commitment to the expansion (Office of Gov. Snyder release, 2/6).
• Minnesota: Gov. Mark Dayton (D) said in a statement on June 28 said, “Today’s ruling will be met with relief by the Minnesotans whose lives have already been improved by this law.” Dayton in 2011 used federal money to expand Medicaid early to 84,000 adults with annual incomes below $8,400 (Lohn, AP/San Francisco Chronicle, 6/28).
• Missouri: Gov. Jay Nixon (D) on Nov. 29 announced that Missouri will participate in the Medicaid expansion. Nixon said he will include the expansion in the state budget proposal he submits to lawmakers. “We’re not going to let politics get in the way of doing the best thing for our state,” he said (Crisp, “Political Fix,” St. Louis Post-Dispatch, 11/29).
• Montana: Gov.-elect Steve Bullock (D) — who takes office on Jan. 7 — on Jan. 4 announced several changes to outgoing Gov. Brian Schweitzer’s (D) two-year budget recommendations, but retained the proposal to expand Medicaid. During a news conference, Bullock said the Medicaid expansion is part of his “Access Health Montana” plan to increase health care coverage for more Montana families. (Johnson, Billings Gazette, 1/5; Johnson, Montana Standard, 1/5).
• Nevada*: Gov. Brian Sandoval (R) on Dec. 11 announced that the state will participate in the Medicaid expansion. “Though I have never liked the Affordable Care Act because of the individual mandate it places on citizens, the increased burden on businesses and concerns about access to health care, the law has been upheld by the Supreme Court,” Sandoval said in a statement, adding, “As such, I am forced to accept it as today’s reality and I have decided to expand Nevada’s Medicaid coverage” (Damon, Las Vegas Sun, 12/11).
• New Jersey: Gov. Chris Christie (R) in his Feb. 26 budget address announced that New Jersey will participate in the Medicaid expansion. The ACA provision is expected to extended Medicaid coverage to about 300,000 uninsured New Jersey residents (Delli Santi, AP/San Francisco Chronicle, 2/26).
• New Hampshire: Gov. Maggie Hassan (D) in her Feb. 14 budget address said that New Hampshire will opt into the ACA’s Medicaid expansion because “it’s a good deal…[that will] allow us to save money in existing state programs, while increasing state revenues.” A state report estimates that the expansion will cost New Hampshire about $85 million through 2020, but will bring in $2.5 billion in federal funds and help reduce the number of uninsured residents from roughly 170,000 to 71,000 (Ramer, AP/Seacoastonline.com, 2/14)
• New Mexico: Gov. Susana Martinez (R) on Jan. 9 announced that her state will participate in the Medicaid expansion, which potentially could extend health coverage to nearly 170,000 additional low-income uninsured residents. Martinez noted that contingency measures will be established if federal funding for the expansion diminishes, which would mean scaling back the expansion by dropping newly covered beneficiaries from the Medicaid rolls (Massey/Montoya Bryan, AP/Santa Fe New Mexican, 1/9; Schirtzinger, Santa Fe Reporter, 1/9; Reichbach, New Mexico Telegram, 1/9).
• North Dakota*: Gov. Jack Dalrymple (R) in January said the politics associated with the ACA should not prevent North Dakota from participating in the Medicaid expansion. He is supporting a bill that would allow the state health department to access federal funds allocated through the ACA. Dalrymple also said he will include the expansion in his budget proposal and that members of his staff will testify in favor of the expansion before state lawmakers (Jerke, Grand Forks Herald, 1/12).
• Ohio*: Gov. John Kasich (R) on Feb. 4 announced that the state will be participating in the Medicaid expansion, the Cleveland Plain Dealer reports. He made the announcement in his two-year budget announcement, but warned that Ohio would “reverse this decision” if the federal government does not provide the funds it has pledged to the expansion (Tribble, Cleveland Plain Dealer, 2/4).
• Rhode Island: Gov. Lincoln Chaffee (I) in a statement on his website on June 28 said, “I have fully committed to ensuring Rhode Island is a national leader in implementing health reform whatever the Supreme Court decision, and this just reinforces that commitment.” According to Steven Costantino, the state’s secretary of health and human services, “The expansion is easy to do and makes sense.” Moreover, on July 12, USA Today reported that Chaffee planned to participate in the expansion (Chaffee statement, 6/28; Wolf, USA Today, 7/12; Radnofsky et al., Wall Street Journal, 7/2).
• Vermont: Gov. Peter Shumlin (D) on June 28 said Vermont’s Medicaid program already meets the requirements under the health reform law’s Medicaid expansion (Steimle, WCAX, 7/1).
• Washington*: In an email responding to a query by American Health Line, Karina Shagren—a deputy communications director in Gov. Chris Gregoire’s (D) administration—in early July said “the governor supports the Medicaid expansion—and Washington will move forward.” U.S. Rep. Jay Inslee (D)—who supports the expansion—was elected governor on Nov. 6 (Shagren email, 7/5; Washington Secretary of State website, 11/12).

UNDECIDED/NO COMMENT (6 states)

• Alaska*: Gov. Sean Parnell (R) on Aug. 8 said he is guarded on the expansion “because our history with the federal government right now is they cut what they promise to fund.” Parnell said he wants to thoroughly understand the costs to the state before making a decision (Bohrer, AP/San Francisco Chronicle, 8/8).
• Indiana*: Gov. Mitch Daniels (R) in a statement on June 29 said, “Any decision to expand Medicaid in 2014 is entirely the province of the next General Assembly and governor.” U.S. Rep. Mike Pence (R) was elected governor on Nov. 6. In a position statement earlier this year, Pence noted that the Medicaid expansion would double “down on an already broken and unaffordable Medicaid system.” Addressing the Affordable Care Act as a whole, he wrote, “I believe the State of Indiana should take no part in this deeply flawed healthcare bureaucracy” (Office of Gov. Daniels release, 6/29; Pence letter).
• Kansas*: Gov. Sam Brownback (R), who has been a vocal opponent of the Affordable Care Act, has not stated whether to opt in or out of the Medicaid expansion, the Associated Press reported on Nov. 9 (AP/NECN, 11/9).
• Tennessee: Gov. Bill Haslam (R) has not decided whether Tennessee will participate in the Medicaid expansion. However, two lawmakers—Sen. Brian Kelsey (R) and Rep. Jeremy Durham (R)—already have committed to introducing legislation that would block expansion, and the state’s new Republican supermajority in the General Assembly means such a bill could pass (Bohs, “Bohs Column,” The Jackson Sun, 11/9).
• Utah*: In an email responding to a query by American Health Line, Nate McDonald—public information officer for Gov. Gary Herbert (R), who won re-election in the state’s gubernatorial race in November 2012—said “[n]o official decision” has been made on the Medicaid expansion (McDonald email, 11/9).
• West Virginia: Gov. Earl Ray Tomblin (D) in a statement on his website on June 28 said, “We know what the law is but as I’ve said before, I will continue to do what is best for West Virginia … We’re going to review the Supreme Court’s ruling, and work with our federal delegation on how we move forward.” In the state’s gubernatorial race in November 2012, Tomblin was re-elected (Office of Gov. Tomblin release, 6/28; AP/Marietta Times, 11/7).