On paper, Indiana Gov. Mike Pence comes off as an unlikely candidate for embracing any part of Obamacare. He’s a darling of conservatives, and was a vocal opponent of the Affordable Care Act during his time in Congress. “Make no mistake about it, the president's healthcare bill would do nothing to lower the cost of healthcare and would be a disaster for the American economy,” Pence said on the House floor in July 2009. “If Obamacare passes, you will probably lose your health insurance and you might just lose your job.”
And yet, in spite of all that opposition, Pence is moving forward with a plan to use federal Medicaid dollars made available by the ACA to expand health coverage in his state. He’s also trying to convince conservatives that his plan has nothing to do with the Affordable Care Act and is actually a fulfillment of conservative healthcare reform. “Reforming traditional Medicaid through this kind of market-based, consumer-driven approach is essential to creating better health outcomes and curbing the dramatic growth in Medicaid spending,” Pence said.
Going by the initial reaction, conservatives aren’t buying it.
The Heritage Foundation called Pence’s decision a “disappointment.” The Federalist slammed Pence’s scheme as “merely the latest iteration of full Obamacare Medicaid expansion thinly disguised as a conservative entitlement reform.”
Pence’s proposal is to expand coverage in his state through the Healthy Indiana Plan, an existing program that provides health spending accounts to low-income Indiana residents who don’t qualify for Medicaid. Right now enrollment in the program is limited to those making less than 100 percent of the federal poverty level; Pence wants to lift that coverage limit to 138 percent and have the feds cover most of the cost of the expansion, as it would if the state were to simply expand Medicaid.
That’s where Pence is running into trouble with conservatives. The conservative argument against expanding Medicaid is that the federal government can’t be trusted to honor its financial promises, and when that funding dries up the state will be on the hook for all the new Medicaid enrollees. Pence is trying to pull a fast one on the right, arguing that he’s not “expanding Medicaid” while still taking the Medicaid expansion money.
Pence’s plan is still subject to federal approval and it’s not clear whether it will provide better health outcomes than a straightforward Medicaid expansion, but Pence’s willingness to at least try to work within the Obamacare framework is an encouraging sign that ideological resistance to the law is collapsing in the face of moral and practical considerations. “This is a win for everyone,” writes Arit John at the Wire. “Every time a Republican governor follows in Arkansas's footsteps with a conservative alternative, it makes a better case for Medicaid-friendly officials in other states like Texas and Florida.”
The bottom line for red states that rejected expanded Medicaid funding is that the decision, while ideologically satisfying, carried with it the reality of denying health coverage to people who really need it. Grappling with that reality might piss off the activists and curb your ambition for the Republican presidential nomination, but the benefit it confers is very real.