How the Republicans are still blocking a key plank of Obamacare

Seventeen states, most in the South or Mountain West, are unabashedly rejecting any consideration of expanding their Medicaid programs under the new health care law, as Democrats now privately say some states may not accept additional federal funds under the Affordable Care Act until President Obama leaves office nearly three years from now.

Liberal activists in Texas and North Carolina say there is little hope of expanding Medicaid in their states in 2014, with conservative lawmakers and governors who were already opposed to the expansion now further emboldened by the dismal rollout of the health care law last fall. Democrats in Florida and Georgia, effectively conceding defeat in the health-care debate for now, have shifted their energy to the fall campaign, hoping to force GOP governors in those states  out of office by highlighting their opposition to Medicaid expansion.

“People have to roll up their sleeves and work for the long term,” said Ginny Goldman, executive director of the Texas Organizing Project, at a recent health care conference put on by the pro-ACA group Families USA.

This resistance comes despite polls showing that the majority of people in many of these states back Medicaid expansion and stories emerging all over the country of low-income people getting covered in the 25 states who have accepted the new federal funds for the program.

The non-partisan Urban Institute estimates that more than four million people won’t get health insurance as a result of these states’ decisions, because they don’t qualify for Medicaid under the pre-ACA rules and have too little income to get the subsidies under the law. Many of these states, like Louisiana and Mississippi, have high black populations, and at least several hundred thousand African-Americans fall into this so-called coverage gap.

And these 17 states illustrate the enduring political divide over “Obamacare,” as voters in all but two of them (Florida and Wisconsin) backed Mitt Romney over President Obama in 2012.

Obama administration officials say they take a long view of the expansion. They note that the original version of Medicaid wasn’t expanded to all 50 states until 1982, 17 years after it passed.

And they point to a bloc of seven states, including conservative bastions like Utah and Tennessee, that are actively considering some kind of Medicaid expansion this year.

“We believe over time states will see the benefits of taking advantage of the significant federal financial contribution of expanding Medicaid coverage,” said Erin Shields Britt, director of communications at the Department of Health and Human Services.

But the conservative resistance has been strong, belying the optimism of Obama administration officials.

“I think the vast majority of states will come in right away,” then-White House Chief of Staff Jack Lew said in an interview on Fox News two years ago, predicting states would quickly embrace the Medicaid funds after a 2012 Supreme Court decision allowed states to opt out if they chose to.

The early signs were positive for the White House. Last year, several Republican governors, such as New Jersey’s Chris Christie and Arizona’s Jan Brewer, announced they would expand their Medicaid programs, and it appeared other Republicans would soon do the same.

But that momentum has stalled. After Florida Gov. Rick Scott said he backed Medicaid expansion last year, Republicans in the state legislature blocked the funding for it. North Carolina GOP lawmakers passed a provision that expressly forbids the state from taking the Medicaid funds.

And some GOP governors up for reelection this year, such as Georgia’s Nathan Deal, have doubled down on their opposition to the Medicaid program, despite its popularity with voters overall, casting it an example of overreach by the federal government.

“We will not allow ourselves to be coerced into expansion. Be assured, I am prepared to fight any intrusion into our rights as a state,” Deal said in his “State of the State” address earlier this year.

Obama administration officials, most notably Secretary of Health and Human Service Kathleen Sebelius, are frequently visiting these states and making the case they are losing out on federal dollars that would go to hospitals that provide care for people who are uninsured.

The law funds the entire Medicaid expansion through the federal government for the next three years and then 90 percent of it after 2016, but some Republican state legislators and governors said they are worried the federal government will renege on this funding pledge, despite the Obama administration constantly pledging it will not.

“We thought (state) lawmakers would be moved by the economic arguments,” said Jen Bersdale, executive director of Missouri Healthcare for All, a group pushing for the expansion there, which is supported by the state’s Democratic Gov. Jay Nixon. “But instead they would start talking about [the] federal government pulling out money.”

And the broader political divide over the law, already strong, is likely to be heightened as the 2014 elections approach and Republicans look to campaign against congressional Democrats who voted for the law.

“I was feeling good until Americans for Prosperity started attacking (North Carolina Democratic U.S. Senator) Kay Hagan,” said Adam Searing of the North Carolina Justice Center, referring to a conservative group that is running commercials in the state highlighting Hagan’s support for the health care law.

“That polarized everything immediately again,” said Searing, who supports Medicaid expansion in the state.