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Indiana's Pence sees the writing on the Medicaid wall

When even Mike Pence realizes Medicaid expansion is probably necessary, it's a reminder that the dead-enders are fighting a losing battle.
Activists Demonstrate In Support Of Medicaid Expansion And The Affordable Healthcare Act
Deborah Dion and other protesters gather in the office of Florida State Rep. Manny Diaz as they protest his stance against the expansion of healthcare coverage on September 20, 2013 in Miami, Florida.
When many Republican governors balked at Medicaid expansion under the Affordable Care Act, apparently motivated by nothing more than partisan spite, they may not have fully thought through the policy consequences. As we were reminded this week, hospitals in Medicaid-expansion states are treating fewer and fewer uninsured patients (i.e., patients who can't pay their medical bills), while hospitals in GOP-led states struggle.
Just yesterday, Arkansas' Surgeon General and the president of the Arkansas Hospital Association told state lawmakers there's been "a dramatic decline in the number of uninsured patients hospitals are seeing" since the state embraced Medicaid expansion, in its case through the so-called private option. There's been no similar decline in "red" states.
The question for Republican policymakers in non-Medicaid-expansion states, then, is how long they can reasonably expect to hold out. Or more to the point, how much longer they intend to prioritize their contempt for President Obama over their states' best interests.
Aaron Carroll reported yesterday one far-right ACA opponent who is slowly yielding to reality.

Another die-hard opponent of the Affordable Care Act may be finding a way to expand Medicaid. Few have stood as firm against Obamacare as Gov. Mike Pence of Indiana, but on Thursday he announced a new proposal that would accept federal funds for increased coverage of low-income state residents -- though by giving them access to private insurance plans rather than standard Medicaid. Mr. Pence now joins conservative leaders of Arkansas, Michigan, Pennsylvania and Utah who have recently found or are trying to find ways to "get to yes" with the federal government on this issue. If Mr. Pence can find a way, it's likely some of the 23 holdout states will eventually follow.

For those unfamiliar with Pence, the Indiana Republican is a former six-term congressman, where Pence developed a reputation for being a very conservative Republican who served in the party's leadership as the Conference Chairman. No one -- no one -- would ever accuse Pence of moderation, and he's begun quietly making noises about a possible presidential campaign in 2016, to the delight of far-right activists.
This context is important because when even Mike Pence realizes Medicaid expansion -- or at least some version of it -- is probably necessary, it's a reminder that the dead-enders are fighting a losing battle.
In this case, Pence isn't just embracing the ACA policy wholesale, and the details he has in mind matter. Adrianna McIntyre explained that the Indiana Republican is effectively endorsing the Obama administration's policy, "but don't expect the governor to frame it that way."

Pence has proposed to expand an existing state program, the Healthy Indiana Plan, to extend affordable coverage to all Hoosiers below 138 percent of the federal poverty line. Indiana would pay for that expansion using Obamacare's Medicaid expansion funds. Healthy Indiana is popular with its beneficiaries, but the program would have to change to become Obamacare-compliant. Right now, for example, it imposes annual and lifetime dollar limits, doesn't cover maternity care, and requires monthly contributions from most enrollees. The Department of Health and Human Services made it clear that some of these rules were unacceptable if Indiana wanted federal funds for a full Medicaid expansion. He's billing this move as an "alternative" to Medicaid expansion, because the state is seeking permission from the feds revamp the Healthy Indiana Plan. But Indiana's special expansion still needs to play by Obamacare's rules.

It's not a done deal and the Obama administration will still have to consider Pence's proposed model before it moves forward. But in recent years, administration officials have been quite accommodating towards states looking for Medicaid solutions, and so long as Pence is prepared to play by the rules, it's realistic to think the federal HHS will give Indiana the green light.
The question then becomes how long the other states intend to hold out for no good reason. The answer matters: if every state expands Medicaid -- the way the policy was intended to work before the Supreme Court intervened -- it would mean another 5 million low-income Americans would have access to affordable medical care.
Postscript: Also keep an eye on Montana, where the state's Democratic governor and GOP legislators have reportedly been having private meetings to discuss the possibility to adopting Medicaid expansion, too.