Medicaid and the Primaries

By Emma Sandoe

The candidates have said little about health care over the 2016 campaign season. But the debates over Medicaid expansion continue to loom large over the primary elections as the politics within states are put on display. In all of the states that are showcasing early primaries, the state legislatures are actively debating Medicaid policy.


Iowa was the second state to expand Medicaid using the 1115 waiver authority. Since the state expanded coverage about 116,000 Iowans have gained Medicaid coverage through expansion or through the other Medicaid eligibility programs that the state offers.

Separate from the conversation about expansion the governor has proposed a controversial change to move all of the Medicaid beneficiaries onto private health insurance plans paid for by Medicaid. This ambitious plan required additional complexities such as setting up provider networks and informing beneficiaries of the change. The federal Centers for Medicare & Medicaid Services (CMS) recently asked the state to delay the implementation date. In other states, the private plans are phased in by population group (pregnant women, children, people with disabilities, etc) and often people with disabilities are excluded. Private insurers are often not equipped to provide services to high need individuals and the payment system incentivizes these high utilizers to be denied care

Former Secretary Hillary Clinton brought this issue to attention by warning voters that this policy could result in cuts in health care services. No other candidates made news on the highly contentious issue within the state. The launch is now delayed to March 1st and is likely to remain a political issue within the state.

New Hampshire

New Hampshire passed Medicaid expansion in August of 2014 and now has a waiver for premium assistance. Since then 47,000 people have signed up for expansion coverage. The original expansion plan was a close vote and only extended Medicaid through the end of 2016. The Republican House leadership has supported a two-year extension to the expansion program, citing the state’s opioid epidemic as the catalyst to that vote. On Wednesday, the extension passed the House 207-136 (yes, there are that many people in the New Hampshire legislature).

Former Governor John Kasich who came in second in the New Hampshire primary is the notable exception to the Medicaid silence. He expanded Medicaid in Ohio in 2013 using a state control board, side stepping the Ohio legislature. While this decision has been controversial in the Republican party since Kasich launched his campaign, the issue is expected to heat up as the campaign enters South Carolina. Former Governor Jeb Bush has launched an attack on Kasich, appealing to a voter base less sympathetic with the decision. Bush has touted his efforts to stop the expansion in Florida in his campaign.

South Carolina

South Carolina is one of the first states to vote in the primary that have not expanded Medicaid. Ten of the 17 states in the South have not expanded Medicaid. Approximately 123,000 South Carolina residents would qualify for Medicaid coverage in the state but currently fall in the Medicaid “gap.” Governor Nikki Haley has asserted her opposition to expansion and one of the state’s strongest proponent in the legislature, Senator Clementa Pinckney, was killed in the Emanuel AME Church shooting in July. There has been little action in the legislature to move an expansion bill forward.


Nevada expanded Medicaid as part of the initial 2013 open enrollment period with coverage beginning on January 1, 2014. The state will be one of the first states to vote with a large Hispanic population. A recent report for the Georgetown’s Center for Children and Families found that Nevada has reduced the uninsurance rate for Hispanic children more than any other state in the country. While Medicaid expansion primarily covers adults, states that have expanded have seen greater participation across their Medicaid programs.

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