This April 1, Texas Gov. Rick Perry joined Sen. Ted Cruz in declaring that Texas would not accept $100 billion in Obamacare funds to extend Medicaid to at least 1.5 million of his state's poor. "Seems to me April Fools' Day is the perfect day to discuss something as foolish as Medicaid expansion," he told reporters.
Perry's stance is yet another example of how the Republican Party, especially its Tea Party faction, is fixated on the Affordable Care Act. In its quest to kill or cripple President Obama's most significant legislative accomplishment so far, it has forced the government to shut down, demolished the GOP's standing in the polls and brought the nation to the edge of default. Most Republican governors, even those representing large shares of poor and uninsured citizens, have toed the party line, refusing federal funds that would help extend Medicaid.
But three Western Republican governors are defying party ideology, and political risk, by accepting the Medicaid expansion. Nevada, Arizona and New Mexico have some of the highest rates of uninsured in the nation, not to mention a relatively high dependency on the federal government overall. North Dakota's Republican governor is also participating, despite his state's comparatively low number of uninsured. Together, these governors are sending a message to Washington: In the West, pragmatism can still trump party politics, especially when the public's interests are at stake.
Thanks to the way Medicaid eligibility varies from state to state, the Affordable Care Act potentially left out uninsured people who make too much to qualify for state Medicaid, yet too little to qualify for federal insurance subsidies. To cover the gap, the new law required states to expand Medicaid eligibility to anyone earning less than 138 percent of the federal poverty level. But the Supreme Court, while upholding most of Obamacare, left the Medicaid expansion up to the states. So far, 24 states and D.C. have signed on. Only eight of the GOP's 30 governors opted in, however. Nevada's Brian Sandoval was the first, followed by New Mexico's Susana Martinez. Jack Dalrymple of North Dakota signed off in the spring, while Jan Brewer went to the mat for Arizona's Medicaid in January.
Maybe these leaders are already "hooked on the sugar, hooked on the subsidies," as Sen. Cruz told Rolling Stone magazine. Or, maybe they're looking out for their states' best interests. With more than 20 percent of their residents lacking health insurance, Nevada and New Mexico trail only Texas in their rates of uninsured.
Expanding Medicaid is consistent with Martinez's humanitarian streak and the policies that have contributed to her popularity in blue-tinged New Mexico. In 2011, the ex-Democrat balanced New Mexico's budget without slashing state Medicaid funds. And as the shutdown loomed, Martinez told a reporter that she couldn't let Washington's dysfunction and polarization affect implementing the Affordable Care Act in her state.
Casting a wider social safety net also looks good for the state's finances. Analysts at the University of New Mexico and the state Legislature predict that the expansion, which will cover about 170,000 New Mexicans, will save the state hundreds of millions of dollars. That may have swayed Martinez, says Kim Posich, director of the New Mexico Center on Law and Poverty. "I know it was not an easy decision for her," he says. "She's taking a lot of hits on it now from conservatives."
Democrat-led legislatures backed Martinez and Sandoval. But Jan Brewer's battle in Arizona has been harder-fought, and with higher political stakes. She demonstrated her opposition to Obamacare by signing onto the lawsuit that took it to the Supreme Court. But like her Western colleagues, she wanted the Medicaid expansion for practical reasons. In 2011, recession-related budget shortfalls forced her state's Medicaid program to freeze new enrollments for childless adults currently eligible thanks to a state voter mandate. For the Arizonans left out in the cold since then, the expansion is really a restoration of coverage, explains Monica Coury, a spokesperson for Arizona's Medicaid agency.
Nevertheless, Arizona's Republican-led Legislature refused to go along. After months of inaction, Brewer forced its hand by threatening to veto every bill they sent her. The Legislature voted in June, giving Brewer a huge win. Even Montana's Democratic governor, Steve Bullock, couldn't prevent his GOP Legislature from joining Republican-led Idaho, Utah and Wyoming in rejecting Medicaid.
For Brewer, though, the fight to insure nearly 300,000 Arizonans isn't over. Hard-liners threatened to punish her Republican supporters in the 2014 election, and the conservative Goldwater Institute is suing to repeal the Medicaid expansion.
In September, with the nation's capitol on the verge of shutdown, Nevada's Gov. Sandoval gave D.C. a civics lesson during the weekly Republican Party radio address. "We sit down, put partisanship aside, talk through our disagreements and find common ground," he explained. Sometimes, that might mean defying your own party to accept hundreds of millions in big-government funding, if it benefits your state's residents.