Medicaid expansion cleared the state Senate and earned the endorsement of Gov. Rick Scott (R) this year. But it was held up in the more conservative state House. With Texas out of the picture until 2015, Florida is likely to be one of the top priorities for the administration and advocates: More than 750,000 people fall in the coverage gap in that state alone.
But the internal politics could be tricky. House Speaker Wil Weatherford (R) held his chamber together in opposing the expansion last year, and he is widely believed to have higher ambitions. Scott, too, is a bit of wild card. He endorsed expansion last year, but he wasn't exactly a full-throated supporter during the legislative debate.
With his reelection campaign looming in the fall, it's not clear how hard Scott would be willing to fight for a major provision in a law he built his political career campaigning against. But he's also surely aware that more than 60 percent of his state's residents have said they support expansion.
The state is approaching Medicaid expansion unlike any other -- and just elected a Democratic governor. Last year, the GOP-controlled legislature established a new commission to study the expansion. It hasn't reached an agreement yet as its members debate other reforms to the program before voting for expansion -- but if expansion earns their support, it would pave the way to approval in the full legislature.
Governor-elect Terry McAuliffe (D), meanwhile, ran in part on his support for Medicaid expansion. His election should brighten the prospects in the coming legislative session. Expansion in Virginia would extend coverage to almost 200,000 people.
The incoming governor is already pressing the business community to get involved. "If Medicaid is not the business community's No. 1 priority in your conversations with the General Assembly, it is not going to happen," he told a group of CEO's recently. "To the CEOs here, the effort will not pass if you do not take up the effort yourself."
This might have been the biggest tease for expansion advocates. Gov. Maggie Hassan (D) has endorsed expansion, and the House of Representatives is solidly Democratic. But the Republican-controlled Senate stopped expansion during the regular legislative session earlier this year.
When Hassan called a special session last month, there was optimism that a deal could be reached. But it didn't materialize, with the Senate Republican leader saying that they were "close in principle" but not on the details. Reports state that the GOP supports a privatized Medicaid expansion, as Arkansas has done, while Democrats wanted a traditional expansion.
But with the debate seemingly coming down to details, the issue is expected to be at the top of the legislative agenda next year. “Our providers are ready for expanded health coverage, our businesses are ready, our people are ready, and I am ready,” Hassan said in a statement after the special session talks failed. “We will keep working and there will be more votes."
The path to expansion is less certain here than the others, but a number of factors are working in its favor. The state's hospital association has been one of the most vocal in the nation in lobbying for expansion. One hospital has already closed this fall and blamed the lack of Medicaid expansion, which would cover nearly 320,000 people.
The state legislature also made an unusual move this summer that some advocates believe portends expansion. It set a cap on sales tax refunds that non-profit organizations could receive, but set it so high that it wouldn't actually apply to any existing groups. Don Taylor, a public policy professor at Duke University, told TPM that it could likely be lowered, targeting non-profit hospitals -- and the resulting revenue could help pay the state's portion of the Medicaid expansion starting in 2017.
Gov. Pat McCrory (R) also cracked open the door for expansion in a recent interview. “I think come February, we are going to get better numbers on how the Medicaid roles are being impacted by the implementation of Obamacare and that will be a major signal to us," he told WFDD. "People will come out of the woodwork to sign up for Medicaid that are qualified for the program. We don't know how many of those people will sign up and if we have enough money budgeted for those people and that is what we need to know before we expand the program."
It all comes down to Gov. Paul LePage (R). The state legislature approved Medicaid expansion legislation, but the governor vetoed it. He hasn't wavered in that position, but a top Republican legislator is reportedly working to craft a new compromise that would be more amenable to the governor. The legislature already came close to overriding LePage's veto, opening an alternative path.
It's also possible that LePage's mind could be changed. His opposition doesn't seem to be ironclad; he said he could support it if the federal government picked up even more of the tab when states begin having to foot part of the bill in 2017, or if the feds allowed the state to institute Medicaid reforms. Plus he's a deeply unpopular governor facing reelection in 2014 -- and his top Democratic opponent, U.S. Rep. Mike Michaud, has endorsed expansion.
"It’s not just good economics; it’s the morally right thing to do," Michaud wrote on his campaign website.
Other states to watch: Tennessee (where Gov. Bill Haslam (R) has tried -- without success thus far -- to reach an agreement with the administration on an alternative expansion); Indiana (where Gov. Mike Pence (R) is also working on an alternative plan); Iowa and Pennsylvania are already actively negotiating with the Obama administration on their own expansion plans.