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Why 2018 could lead to more Medicaid expansion

It's never too early to start thinking about the upcoming 2018 elections. And while a lot of the focus so far has been on the House, a handful of hotly contested gubernatorial races could have higher stakes for health care — specifically, for the Affordable Care Act's Medicaid expansion.

A raft of open governors' races next year will give Democrats a chance to replace some of the most stridently anti-expansion governors in the country — and, if they win even a few of those races, the chance to cover millions of currently uninsured people even as the Trump administration drags its heels on so much of the ACA.

Data: Kaiser Family Foundation, The Cook Political Report; Note: Maine, a toss up state, was not included due to insufficient Medicaid data; Chart: Andrew Witherspoon / Axios
  • 15 non-expansion states will hold gubernatorial elections this year or in 2018. Ten of those will be open seats.
  • Democrats won't win all of those races. But several of their best political opportunities are in the states where Medicaid expansion would cover the most people.
  • One of the biggest battlegrounds: Florida, where Gov. Rick Scott will be term-limited next year. The Cook Political Report considers Florida a toss-up. And if Scott's successor is more amenable to the Medicaid expansion, nearly 800,000 Floridians could gain coverage, according to the Kaiser Family Foundation's estimates.
  • Maine Gov. Paul LePage — one of the ACA's loudest critics — is also leaving office, and one of the expansion's biggest defenders — Sen. Susan Collins — might run to replace him.
  • Virginia's state legislature has previously come up just a few votes shy of adopting the expansion, which would cover some 225,000 people.

Why it matters: There's not much the Trump administration could do to stop more states from signing on to the Medicaid expansion, especially if those states don't seek waivers from certain structural rules as part of the process. And that means Democrats, already energized by the health-care fight, have a real chance to build on the ACA's coverage gains, even under a hostile administration — if they can get their act together at the state level.

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