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Mike Nowatzki, Published December 25 2013

North Dakota a rare red state with GOP governor pushing for Medicaid expansion

BISMARCK – Their weather may not have much in common, but when it comes to politics, Arizona and North Dakota aren’t far apart.

Both states lean heavily Republican, led by Republican governors with state Legislatures controlled by GOP supermajorities in both houses. A solid majority of both states’ voters also supported Mitt Romney over Barack Obama in the 2012 presidential election.

And they have something else in common: They’re the only “red” states whose Republican governors successfully pushed for the Medicaid expansion portion of Obama’s Affordable Care Act, despite their opposition to its other provisions.

In Arizona, that’s prompted a lawsuit by 36 Republican lawmakers seeking to block the law pushed by Gov. Jan Brewer from taking effect Jan. 1.

Meanwhile, North Dakota’s Medicaid expansion has moved ahead with far less drama since the Legislature passed a law authorizing the expansion and Gov. Jack Dalrymple signed it in April.

Dalrymple and Brewer are the minority among GOP governors nationwide when it comes to supporting Medicaid expansion. Of the 30 Republican governors, only eight are going along with Medicaid expansion, and six of them are in states that supported Obama in 2012.

In an interview last week, Dalrymple, who included Medicaid expansion in his proposed budget for 2013-2015, said the potential political blowback of his decision “has not entered into my thinking.” He said he has looked at the issue strictly from the standpoint that the expansion could make an additional 20,500 to 32,000 North Dakotans eligible for Medicaid, according to a Department of Human Services estimate.

“There really is no good reason to stand in the way of 20,000 North Dakotans having the opportunity to get health insurance coverage at no cost to themselves,” he said. “I think that really is the overriding consideration.”

Dalrymple said it’s important to note that the Legislature approved the expansion – 57-36 in the House, 33-14 in the Senate, with all of the “nays” coming from Republicans – unlike in some other red states where it was purely the governor’s call.

North Dakota is one of 25 states implementing Medicaid expansion in 2014. Two other states, Indiana and Pennsylvania, have pending waivers for Medicaid expansion plans that would take effect after next year, according to the Kaiser Family Foundation, which tracks progress of the Affordable Care Act.

The act required states to expand Medicaid coverage to eligible residents with incomes below 138 percent of the federal poverty line, which is about $32,500 for a four-person household. But a June 2012 ruling by the U.S. Supreme Court had the effect of allowing states to opt out of Medicaid expansion.

As of mid-December, North Dakota’s Department of Human Services had received 900 applications at the state and county levels for expanded Medicaid coverage and 1,600 applications through the federal marketplace, DHS Executive Director Maggie Anderson said.

The department recently hired a vendor, Automated Health Systems, to begin processing the applications.

“We’re shooting toward all of those people have coverage on Jan. 1,” said Julie Schwab, director of medical services at DHS.

Officials didn’t know how many applications to expect, Schwab said. Because there’s no open enrollment period, patients may apply for coverage once they are in a medical facility and need it, she said, noting there’s a three-month retroactive period for coverage.

Anderson said Medicaid expansion will make more people eligible for the program and won’t necessarily alleviate the burden on county social services offices. However, the online eligibility system “should actually make the process more simple and streamlined, where some people who may apply through the county office or go directly in and hand a paper application in may sit at their kitchen table and apply online,” she said.

Schwab said that by providing people with health insurance coverage for the services they’re seeking, Medicaid expansion may also lessen the financial burden on health care facilities that have been forced to swallow the costs of uncompensated care, particularly in emergency rooms where patients can’t be refused treatment.

“So hopefully they’ll seek service at the most appropriate place versus an emergency room,” she said.

The state expects to bring in an additional $154 million to $171 million in federal funding during the 18 months of the 2013-2015 biennium that Medicaid expansion will be in effect. Anderson said the state also will spend about $250,000 from its general fund for staff and the administrative contract.

Among bordering states, Minnesota is moving ahead with Medicaid expansion, while Montana and South Dakota are not.

In Montana, where Democratic Gov. Steve Bullock supported Medicaid expansion, House Republicans killed the expansion bill, ultimately aided by a mistaken “no” vote by a freshman Democratic legislator. A coalition of groups known as the Healthy Montana Initiative recently submitted proposed ballot language to put the question to voters next fall, the Washington Post reported.

South Dakota Gov. Dennis Daugaard said in his budget address earlier this month that he’s not recommending to expand Medicaid in the state’s fiscal year 2015 budget, saying implementation of the Affordable Care Act “continues to be unpredictable and chaotic.”