… As Congress prepares to repeal and replace the Affordable Care Act, 14 other states with GOP governors that opted to expand Medicaid under the law may face the same reality Bevin and Hutchinson did: Taking health insurance away from hundreds of thousands of people is a complicated and risky proposition. Medicaid spending for all states was about $532 billion in 2015, with about 63 percent funded by the federal government and the rest by states. In expanding Medicaid under the ACA, Republicans in expansion states chose economics over politics, even though it meant cooperating with a law that nearly all conservatives abhor. That calculus won’t change with the transition in Washington, according to Matt Salo, who heads the National Association of Medicaid Directors.
… In upcoming legislative sessions, many GOP-dominated states are likely to preserve expansion while adding so-called personal responsibility policies that have been proposed in Kentucky and adopted in Arkansas and five other states. Those policies include monthly premiums, copays and work requirements for low-income beneficiaries. … Under the Obama administration, Arkansas, Indiana, Iowa, Michigan, Montana and New Hampshire received federal approval to expand their low-income health care programs for adults under different rules than traditional Medicaid. Arkansas, with its so-called private option, was the first state to receive federal approval for an alternative expansion plan in 2013. Instead of enrolling newly eligible adults in its traditional Medicaid plan, which serves primarily children, pregnant women and the elderly and disabled, the plan for low-income adults substituted private insurance for traditional Medicaid. A bipartisan collaboration between former Democratic Gov. Mike Beebe and the state’s Republican-dominated Legislature, the plan has managed to come in under budgeted costs while covering far more people than originally projected, said Amy Webb, a spokeswoman for the state’s human services agency. After it was approved, Iowa and New Hampshire proposed similar plans. … If the Medicaid expansion remains intact, Kentucky could be the first state to get approval for an alternative plan under the Trump administration. With enough latitude, even holdouts such as Florida, Texas and Virginia might be persuaded to accept federal money to cover low-income adults.