Branstad taking a gamble with stance on Medicaid
It might seem like it’s Iowa Gov. Terry Branstad against the world when it comes to health insurance for the poor.
The number of Iowa lobbyists whose clients favor going along with the so-called Obamacare federal health law and beefing up Medicaid so that it covers more low-income Iowans: 88.
The number registered in opposition to the bill before the Iowa Legislature: Zero.
Yet Branstad continues to rebuff the idea of making Medicaid bigger, and he seems unwilling to back down from his push for a new Iowa-built government health insurance program. His program, the Healthy Iowa Plan, wouldn’t cover as many Iowans and would require the state to pay a much larger share of the cost.
Branstad could face political ramifications if his gamble falls apart, especially if he refuses to compromise and 69,000 working-poor adults lose their state health insurance — a very real consequence of legislative inaction, Iowa lawmakers said.
But he also stands to gain politically from what some political strategists see as the more likely outcome of this battle: Branstad doesn’t get permission from the federal government for his homegrown plan, and he has to expand Medicaid anyway.
The political portrait will be that he did everything in his power to exercise budget discipline, display a free-market mentality and hold off what some conservatives consider a federal power grab, said Robert Haus, a GOP operative and public affairs strategist. Branstad will have protected his standing among budget-conscious independent voters and with his right flank, Haus said.
Some observers scratching heads
In the meantime, Capitol watchers have done a lot of puzzling about what exactly Branstad is doing.
“Certainly there’s been a lot of questions at the Statehouse and among our volunteers that we can’t answer,” said Anthony Carroll, an Iowa lobbyist for AARP, which advocates for older Americans.
Think of it this way, lobbyists said: If the federal government offered to pay 90 percent for highway projects that affected towns across Iowa, but the governor said, “No, let’s go for a state plan that will attract 60 percent funding,” people in those towns wouldn’t be happy.
Branstad has said he wants to reject the larger portion of federal health care money because he doesn’t trust the federal government to fulfill its promise to pay 100 percent of Medicaid expansion’s cost at first and 90 percent in the future. Democratic leaders in the Legislature on Thursday announced they’d be willing to add an option that would let Iowa out of the Medicaid expansion if the federal government were to renege.
“People understand and appreciate the governor’s desire for budget discipline, but they also ask: ‘How can covering fewer people at a much higher cost to the state be more efficient than covering more people at no cost?’ ” said Haus, who is following this issue closely. “If the governor could answer that question, a lot of confusion might be cleared.”
Although the head-scratching continues, it’s wrong to assume the governor is friendless on this, legislative Republicans said.
“I wouldn’t say he’s alone. I can say for myself that I’m standing with the governor until we get more detail,” said Sen. David Johnson, R-Ocheyedan, who is on the subcommittee that oversee the health care budget. “We’d like to have something we can put side by side.”
Would GOP feel heat over expansion?
Still, several Republicans said they’re open to the concept of the Medicaid expansion, which would let an estimated 150,000 Iowans join the 401,582 people already served by the program. Some said they’d rather stick with Medicaid if Branstad’s Healthy Iowa Plan doesn’t cover mental health services, doesn’t cover Iowans’ care at local medical offices and instead forces them to drive to big urban hospitals, or doesn’t appear financially sustainable.
In some other states, Republicans governors and legislators who have come out in support of Medicaid expansion have felt backlash from conservatives and tea party activists.
In Iowa, in a few very conservative legislative districts, Republican could face anger from folks back home and political attacks if they vote to make Medicaid bigger, said Sen. Joni Ernst, R-Red Oak. “It is possible in some of these other districts that they could be primaried,” she said. “At the same time, I think people want us to look at all the options that are available.”
Republicans in most districts would be safe to vote for the Medicaid expansion “if that’s what we decide is the very best thing,” said Rep. Linda Miller, R-Bettendorf, a retired registered nurse who has a passion for health care policy.
Lobbying pressure has yet to reach a boiling point in Iowa, lawmakers said. Lawmakers have spent considerable time talking about the Medicaid expansion bill, Senate File 296, but they noted it’s the only bill filed.
Once Medicaid advocates see the details of Branstad’s plan, Miller said, “I see a lot of different people stepping back and saying, ‘That could work for Iowa.’ ”
Expansion backers hold fast to position
Warming to the Branstad plan is doubtful, said lobbyists who have been the most out-front on the issue, including the Iowa Hospital Association, American Cancer Society’s action network and AARP. Although they’re interested in seeing the details from Branstad, they definitely prefer the Medicaid plan, they said.
They argue that taking as much federal money as possible would cut costs for the state, get quality health care for more Iowans, help lower the cost of private insurance, create jobs and give communities an economic development boost.
But more than 30 lobbyists have registered their clients as “undecided,” including some of the big players, such as the Iowa Health Care Association, representing long-term care providers, and the Iowa Medical Society, representing doctors. And the business community has been largely silent.
Johnson said there’s no rush to decide, but lawmakers must pass a bill before the end of the session.
That’s because IowaCare, which offers limited medical services for people not eligible for Medicaid, expires Dec. 31. No action means no health insurance for vulnerable people, including some chronically ill Iowans who make less than $16,000 per year.
“We will leave this Capitol building with a plan, whatever that is,” Johnson said.
That doesn’t mean Branstad won’t veto the version the Legislature slides onto his desk. If that happens, expect the claws to come out if he seeks re-election as expected in 2014.
Expect election ads to play the issue
Democrats will likely use Branstad’s plan against him, even if it’s adopted — maybe with TV ads that feature Iowans in a terrible health care situation who were left stranded without any insurance, said Timothy Hagle, a political scientist at the University of Iowa.
Democrats won’t put a lot of money into the governor’s race if their candidate is weak, but if a strong Democrat emerges, expect heavy advertising, Hagle said. One problem: The federal Affordable Care Act is complex, “and there are a lot of low-information voters who might be susceptible to advertising that doesn’t tell the whole story,” he said.
Could Branstad pay a political price for digging in behind an idea that so far is less than popular?
“Branstad’s approach is unique because he is asking voters to take a long-term view, which normally doesn’t work well in politics,” said Christopher Larimer, a political scientist at the University of Northern Iowa.
But Branstad has built his credibility through long service to the state, Larimer said. And, unlike with GOP governors in other states, Iowa has favorable economic conditions and money in cash reserves. The state isn’t as desperate as some others to take federal health care dollars to meet requirements in Obamacare.
“He can ask voters to do this and take more of a risk,” Larimer said. Branstad generally isn’t perceived as a rigid ideologue — he has been known to agree with the other party on some issues, such as on a wind power tax credit when Mitt Romney and some national Republicans weren’t keen on it, Hagle said.
But Branstad also has dug in his heels plenty of times in the face of significant opposition, such as when he twice in this term vetoed a tax break for Iowa families making $45,000 or less per year.
Lobbyists point out that this health care stance is consistent with Branstad’s history. He’s never been a fan of “Cadillac plans” of Medicaid and has consistently said everyone should have “skin in the game” on health care costs.
Hagle noted that there’s a difference between compromise and abandoning one’s principles.
“If he believes that his approach is best for Iowa, then compromising would not be a good thing,” Hagle said.
Lobbyists who think Branstad should step away from the precipice said there are plenty of places for him to land. They don’t view him as having backed himself in a corner with his absolutism, they said.
“If he wants to compromise, there are 10,000 ways to do it,” said Kirk Norris, president of the Iowa Hospital Association, which says its members need the new federal money to relieve them of the burden of providing care to hundreds of thousands of uninsured Iowans. “That’s why we just keep trying to chip away at the granite.”