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House Republicans finally revealed their health care plan, the American Health Care Act (AHCA), earlier this month to replace the Patient Protection and Affordable Care Act (ACA or “Obamacare”). Unsurprisingly, AHCA has already come under intense scrutiny on Capitol Hill. Democrats have harshly rebuked the plan, which would retain some portions of the ACA — such as the ban on discriminating against customers with pre-existing conditions — but repeal the individual mandate and change how much insurers can charge enrollees. However, the plan has also drawn some scrutiny from Republicans, not only in Congress, but also from governors across the country.

Medicaid Expansion

Under the ACA, Congress mandated that all states expand their Medicaid programs for residents earning up to 138 percent of the federal poverty level (FPL). However, the the U.S. Supreme Court ruled in 2012 (National Federation of Independent Business v. Sebelius) that the ACA could not force all states to expand their Medicaid programs.

With the Supreme Court making Medicaid expansion optional, 31 states and the District of Columbia chose to expand their Medicaid programs using federal funds offered in the ACA. Normally, federal and state governments both pay for a share of a state's Medicaid program, but under the ACA, the federal government pays for the entire share of the newly eligible population for a state's expanded Medicaid program until 2017, after which the federal contribution reduces each year and settles at 90 percent in 2020. This is a much larger federal share of funding than the normal Medicaid split, which varies by state but is about 60 percent on average.
The proposed AHCA would discontinue the Medicaid expansion program starting in 2020. Federal funds would become unavailable to any new Medicaid expansion enrollees after that date, effectively freezing enrollment. Additionally, AHCA would change the Medicaid funding formula from a matching program, where the federal government pays a set percentage of all dollars spent on Medicaid coverage, to a “per-capita capped” allotment, where the federal government pays states only a set amount per enrollee each year and the amount is set by a formula that is predicted to rise slower than the price of medical care.

Congressional Republicans recognize that medical costs are on the rise, and they believe a spending cap is necessary to help slow down the federal government's Medicaid costs. Governors, who run states that must balance their budgets each year, recognize that fewer federal funds to help pay for their low-income populations' medical care will force them into an uncomfortable political choice: spend more state money to cover Medicaid enrollees (and consequently have less money for budgets items like education) or cut Medicaid benefits for their neediest citizens. The Congressional Budget Office (CBO) estimates that implementation of the AHCA would cause 5 million Medicaid enrollees to lose coverage in 2018, Medicaid enrollment to drop 17 percent by 2026, and cost states $370 billion in federal Medicaid funding.

Republican Governors Express Concerns

Governors from less conservative states and states that opted to expand the Medicaid program under the ACA have taken issue with changes to Medicaid under AHCA.

Among those expressing concern is Ohio Governor John Kasich (R), who was a primary opponent to President Donald Trump last summer. Although Kasich reaffirmed his opposition to the ACA, he cautioned that “phasing out Medicaid coverage without a viable alternative is counterproductive and unnecessarily puts at risk our ability to treat the drug addicted, mentally ill, and working poor who now have access to a stable source of care.” Ohio has added 700,000 Medicaid enrollees since Kasich went around the legislature to expand the program in 2014.

Governor Bruce Rauner (R) warned that “Illinois won't do very well under the changes that they're recommending, which is a big concern to me." Illinois was one of the first states to expand its Medicaid program under the ACA, and now has over 648,000 enrollees in the state. In Nevada, popular Governor Brian Sandoval (R) stated that his position “has been consistent all along with regard to protecting the 300,000-plus lives that have gained insurance as a result of Medicaid expansion.”

The lack of flexibility under the program is also seen as a concern to Arkansas Governor Asa Hutchinson (R), who called the plan “inadequate.” Hutchinson told CNN on Tuesday that "I do not support this bill as it stands... This cannot be the end product." Maine Governor Paul LePage (R), who has been an unorthodox Republican, said he was “very, very discouraged and disappointed with what House Republicans are introducing,” saying the exchanges set up under the ACA are “wonderful.” Mississippi Governor Phil Bryant (R) attacked the plan from the right, calling the proposal “Obamacare Lite” and called on Republicans to “turn back an entitlement.”

Even governors that appeared last week with Vice President Mike Pence expressed their concerns about the bill. Kentucky Governor Matt Bevin (R) said he agreed with criticisms raised by Kentucky Senator Rand Paul (R), but noted the plan was a “work in progress.”

Other Republican governors were more muted in their concerns. Massachusetts Governor Charlie Baker (R) expressed that he wanted to “make sure that we continue to be a state where virtually everybody is covered and people feel they have the access they need and the coverage they need to stay healthy.” Maryland Governor Larry Hogan (R) stressed the need for a bipartisan solution and suggested Congress work with governors to provide a “compromise solution that gets rid of some of the problems and fixes the issues while still protecting as many people as we can.”

Some wanted more time to study the issue, such as Michigan Governor Rick Snyder (R). The bill did have a few supporters, at least regarding the repeal of the ACA. New Indiana Governor Eric Holcomb (R) called it a “correct first step,” Wisconsin Governor Scott Walker (R) called for “more work to be done,” and Florida Governor Rick Scott (R) called it a “work in progress” but an improvement over the ACA.

Democratic Governors Highly Critical

Of course, many Democratic governors came out swinging with criticism of the bill. Oregon Governor Kate Brown (D) called the plan a “radical change that is shortsighted and moves health care backward, not forward.” Montana Governor Steve Bullock (D) called the plan “half-baked,” Washington Governor Jay Inslee asserted that “Trumpcare means less care,” and Connecticut Governor Dannel Malloy (D) did not mince words, predicting “if enacted, this proposal would cause thousands of Americans to die needlessly."

AHCA has already been passed out of two House committees and now sits in the House Budget Committee. House Republican leadership is hoping to aggressively push the bill quickly and get it to the floor by the end of the month.

Late yesterday, the CBO released its score of the AHCA. Critics of the House Republican plan have already pounced on the report — especially its estimate that AHCA would add 24 million uninsured — to attack the AHCA. We'll update this post as governors continue to make their voices heard on this issue. The table below lists full statements from governors and source links.

Update (3/17/2017): In a letter to Majority Leader McConnell and Speaker Ryan, four Republican governors of Medicaid expansion states Ohio Governor Kasich, Michigan Govenror Snyder, Nevada Governor Sandoval, and Arkansas Governor Hutchinson write that although they agree with Preisdent Trump's stated principles to provide states flexibility in managing their Medicaid programs and Secretary Price's committment to meet the diverse needs to state Medicaid populalations, the governors lament that "the current version of the House bill does not meet this test. It provides almost no new flexibility for states, does not ensure the resources necessary to make sure no one is left out, and shifts significant new costs to states."

Andy Wagner and Bill Kramer contributed to this post.

State Governor Statements (link to source)
AZ Doug Ducey (R) It would “result in the single largest transfer of risk ever from the federal government to the states.”
AR Asa Hutchinson (R) Gov. Asa Hutchinson says a Republican proposal to replace the federal health overhaul is "inadequate" for Arkansas, but says the U.S. House should move forward with the proposal so the Senate can address concerns he and other governors have raised. Hutchinson told members of the Political Animals Club on Friday that the House GOP proposal to replace the Affordable Care Act shifts too much costs to the state, doesn't cover all of the people Arkansas is currently covering and doesn't grant the state enough flexibility. More than 300,000 people are being covered through a hybrid Medicaid expansion in Arkansas under the federal law
CO John Hickenlooper (D) “It’s not moving us in the right direction,”
CT Dannel Malloy (D) "...their plan would drive up costs for individuals and families and gut the expansion of Medicaid that has benefited so many in our country. Hard-working Americans deserve access to quality, affordable insurance, and this plan does the opposite – it risks the coverage that millions already have, drives up costs, and limits care. If enacted, this proposal would cause thousands of Americans to die needlessly."
DE John Carney (D) “The Republican proposal to repeal the Affordable Care Act would dramatically change how the federal government funds Medicaid, reduce access to quality healthcare for many vulnerable Delaware families and cost Delaware taxpayers millions each year. We will work closely with Delaware’s congressional delegation to oppose this change, and any other deep cuts to Delaware’s Medicaid program. No law is perfect, and the Affordable Care Act is no exception. But these changes take us in the wrong direction. Any changes to the Affordable Care Act and our nation’s healthcare system more broadly should drive down the cost of care and make our population healthier. This proposal simply shifts costs to those who can least afford it. It would also make our state’s budget challenges even worse.”
FL Rick Scott (R) “This is a work in progress, but it already is much better than Obamacare.”
GA Nathan Deal (R) The Governor is "reviewing the new health care proposal in Congress “and engaging with federal and state officials to assess its impact on Georgia,’’
IL Bruce Rauner (R) "My first blush read is Illinois won't do very well under the changes that they're recommending, which is a big concern to me...I want to make sure that people in Illinois are not left in the lurch or that, you know, there's a lot of pressure to reduce insurance coverage for people in Illinois. I'm very concerned about that."
IN Eric Holcomb (R) "I want to make sure that we're compassionate and cover the Hoosiers that we are right now," Holcomb said at an unrelated event. "I completely believe we need to fix the Affordable Care Act and (House Republicans') repeal was the right first step. But the devil is always in the details."
IA Terry Branstad (R) “I am encouraged Congress is taking the first steps to replace Obamacare.” He added, however, that it would be “premature to comment on any specific provision of the current draft of the American Health Care Act.”
KY Matt Bevin (R) "Senator Paul has ideas of things he thinks need to be a lot stronger," Bevin said. "He's not as impressed with what has currently been offered as some who have currently offered it. Truth be told, I'm not either, so I'm with him. I think there are things that need to be done." Bevin added: "The system is broken. It has been broken for some time. It's quickly becoming insolvent. The beautiful thing is, nobody has the solution yet. It's still a work in progress."
LA John Bel Edwards (D) The House GOP's proposed Affordable Health Care Act "fails a critical test for Louisiana" because it eventually eliminates Medicaid expansion. He's now calling on Congress to reconsider the move as the debate over the proposal advances. "It’s important to remember that many of the faults with the (Obama-backed) Affordable Care Act exist today because the bill was rushed through Congress. We have to get this right," Edwards said Tuesday. "That means taking a deliberative approach to reforming the nation’s health care system."
ME Paul LePage (R) “Right now I am very, very discouraged and disappointed with what House Republicans are introducing….We don’t know what the cost is, but based on what I see and I’m reading and what has happened over the last 15 years, I don’t think it’s an improvement. I think we’re punting the ball, is what we’re doing…..The exchanges are wonderful, [Patients] ought to have copays and ought to have consequences when they miss appointments. … There is nothing wrong with asking people who are able bodied to have skin in the game.”
MD Larry Hogan (R) “We’re going to have to work together in a bipartisan way with governments all around the country and both houses of the federal (government) with input from the governors in the states and come up with a compromise solution that gets rid of some of the problems and fixes the issues while still protecting as many people as we can.”
MA Charlie Baker (R) "We want to make sure that we continue to be a state where virtually everybody is covered and people feel they have the access they need and the coverage they need to stay healthy,"
MI Rick Snyder (R) The governor is still “working through the details of the proposal” and was not prepared to comment.
MN Mark Dayton (D) Democratic Gov. Mark Dayton said this week that he wants to wait and see how the federal government proceeds on health care. “To try to anticipate what they’re going to do when they don’t know themselves … is really impossible,” he said.
MS Phil Bryant (R) "Republican voters who gave majorities to both chambers and delivered the White House do not want Obamacare Lite. I know it takes tremendous courage to turn back an entitlement once it is in place. But with $20 trillion in national debt, we best start making some tough decisions."
MO Eric Greitens (R) "we've got to get this done, and we've got to get this done now." "We have got to, got to provide relief from this terrible tragedy that Obamacare has inflicted on so many families across the state of Missouri,"
MT Steve Bullock (D) "To move on a proposal that is half-baked is not good for Montana and not in the best interests of the country."
NE Pete Ricketts (R) "We've got to find some sort of system to really transition away from what we've done with the expansion because that's too costly, it's too expensive and get to a point where we've got something that can manage our cost better,"
NV Brian Sandoval (R) “My position has been consistent all along with regard to protecting the 300,000-plus lives that have gained insurance as a result of Medicaid expansion…I’m going to take him [Trump] at his word on that and we’ll see what the developments are subsequent to that.”
NH Chris Sununu (R) “We really need to look at what are the long term implications, what are the short term implications. How does it affect our demographics, our constituencies. There’s a lot there to really dig into. We have great folks at Health and Human Services and the Insurance Department to really help gather and understand what the overall implications are, but we have some concerns...we need to make sure that the state has flexibility in what we’re going to do, the state has some say in making sure we can design a system that meets the needs of our citizens. There are parts of this bill that don’t necessarily incorporate that.”
NJ Chris Christie (R) "This is the way governing works: you've got to go in, you make a proposal, and then everybody has their opportunity to come in and pick it apart and try to make it better -- I hope....I'm heartened by the idea that they wouldn't change anything for four years, which I think is good and would give folks a chance to begin to adjust to whatever it would be afterwards,"
NY Andrew Cuomo (D) "After seven years of progress under the Affordable Care Act, the Republican Congress has proposed an inadequate, ill-conceived and unacceptable plan that places the coverage of more than 1 million New Yorkers in jeopardy and, once fully phased in, would shift more than $2.4 billion in costs onto taxpayers and hospitals each year."
NC Roy Cooper (D) "It's important that in the health care reform that the federal government is looking at that they don't leave the states holding the bag."
ND Doug Burgum (R) The plan is "a work in progress." There are "many competing interests, particularly between states with and without expanded Medicaid," which covers low-income people. Wants a state, not national solution.
OH John Kasich (R) "I have always opposed Obamacare and consistently called for it to be replaced with more conservative, market-driven reforms that actually control health care costs. However, phasing out Medicaid coverage without a viable alternative is counterproductive and unncessarily puts at risk our ability to treat the drug addicted, mentally ill, and working poor who now have access to a stable source of care. The right way to fix Obamacare is by Republicans and Democrats working together."
OK Mary Fallin (R) The governor said it would be “very challenging” for her to revamp the program if Oklahoma winds up with less federal money than it currently gets.
OR Kate Brown (D) “The Republicans' proposed health care bill represents a radical change that is shortsighted and moves health care backward, not forward. It would reduce Oregonians' access to care and increase costs for women and seniors. I am especially concerned about how this bill would negatively jeopardize our state’s budget and economy, especially in rural Oregon. I urge Congress and the President to not turn their backs on struggling working families, and instead learn from Oregon’s patient-centered, coordinated care model that has improved health outcomes while holding down costs.”
PA Tom Wolf (D) "This plan does not fix the Affordable Care Act – it would just delay the Republican plan to cut coverage for nearly a million Pennsylvanians, including those who were able to access quality, affordable healthcare after I expanded Medicaid two years ago. It will eliminate healthcare coverage for middle class families while encouraging insurance companies to increase executive salaries. This is a bad plan that would leave thousands of Pennsylvania seniors and families unable to afford access to basic medical care coverage. As I have repeatedly said, any plan that cuts Medicaid or reduces options for affordable, quality health insurance for Pennsylvanians is unacceptable."
RI Gina Raimondo (D) "#Trumpcare puts thousands of Rhode Islanders at risk of losing their health insurance. It makes healthcare more expensive for thousands of Rhode Islanders who can least afford it. I will do everything in my power to oppose #Trumpcare, which benefits millionaires at the expense of hardworking Rhode Islanders. #Trumpcare will destroy our progress to provide affordable, quality healthcare to almost all of our people."
SD Dennis Daugaard (R) “I think it’s very much a moving target,” he said. “What’s being proposed at the outset presumably has been massaged before its unveiling.”
TN Bill Haslam (R) Haslam has not made an official statements but here is some info from the Tennessean. Haslam was part of a coalition of eight Republicans tasked with coming up with health care recommendations. The group of governors met with Tom Price and President Trump during a late February visit to Washington DC. Haslam has publicly stated that he prefers a per captia grant over a block grant system because a per captia system is more flexible. The new healthcare bill transitions the funding mechanism from a federal matching program to a per capita program in which states would get a lump sum per enrollee. The change in funding mechanism also means Tennessee will have greater power to decide who and what benefits to cover. Although Haslam may have issues with other provisions of the bill, he will most likely be pleased with these changes.
UT Gary Herbert (R) “I expect that the Republican side of the aisle will find ways to compromise and hopefully bring some Democrats along with them. The status quo is not acceptable, it is not sustainable...To me, this is probably just a starting point on the discussion,”
VT Phil Scott (R) "We now have one of the lowest uninsured rates in the country, and looking at this, we have concerns that this will march us back," (Governor spokesperson)
VA Terry McAuliffe (D) "It is clear that this bill puts partisan promises ahead of people's health….The Affordable Care Act is not perfect – but it has helped millions of Americans access health coverage that is the bedrock of economic opportunity. On behalf of the people of Virginia, I hope our leaders in Washington will take the proper time and care to put people ahead of politics and only take actions that will build on the ACA to make health care more accessible and affordable, not less.”
WA Jay Inslee (D) “Trumpcare means less care, and it means greater cost for Washingtonians, and neither of those are acceptable."
WV Jim Justice (D) Justice also has concerns about Medicaid, worrying that the proposal will kick West Virginians off Medicaid “and leave them in the cold.” "I have my DHHR secretary looking at the specifics of this new proposal and how it will impact West Virginia and what changes and reductions in all of those government regulations to the law could help our people,” Justice said.
WI Scott Walker (R) "I just still think there's some more work to be done…Our ultimate goal as governors, certainly my goal, is to have ultimate flexibility….I, personally, want to know what the cost is....At some point before the members of the House or the Senate are asked to vote, at a minimum they should not only have the (costs) back but they should have some time to digest it."