Hawley's change of heart reflects evolving politics of Medicaid

WASHINGTON — In 2018, then-Missouri Attorney General Josh Hawley signed on to multistate litigation seeking to overturn the 2010 health care law — a move that, if successful, would have eliminated protections for people with preexisting conditions and ended the expansion of Medicaid to millions of low-income people.

Now, as the senior senator representing Missouri, Hawley finds himself in the unlikely position of defending Medicaid as his fellow Republicans scour for $880 billion to help extend President Donald Trump’s tax cuts and pay for increased funding for border security.

Hawley has made his stance clear in recent weeks: He will not support any proposal that would lead to cuts in Medicaid benefits for Missourians.

“I just want to know, at the end of the day, whatever reforms or packages of things proposed, will it result in reductions to benefits to Missourians? That’s my test.”

What’s changed for Hawley, a longtime critic of the 2010 health care law?

Ballot measure

In 2020, a majority of Missouri voters approved a ballot measure to expand Medicaid in the state to cover more than 348,000 adults making $21,597 a year or less.

“Our voters voted for it. It’s not like the legislature can just adjust it. It’s in our constitution. Our voters voted for it by a big margin,” Hawley said in an interview.

It’s an unexpected about-face for Hawley, a conservative senator with a long-held opposition to the 2010 health care act and an 85% rating from the Conservative Political Action Conference.

“Sen. Hawley is among the most surprising defenders of Medicaid among Republicans in Congress given his past positions,” said Larry Levitt, executive vice president at KFF, a health policy research organization.

Budget amendment

Last week, Hawley joined Oregon Democratic Sen. Ron Wyden in introducing an amendment to the budget resolution that would strip an instruction to the House Energy and Commerce Committee to find $880 billion in savings, most of which would likely need to come from Medicaid. The amendment was not adopted.

Only two other Republicans voted for it: Sens. Susan Collins of Maine and Lisa Murkowski of Alaska. Both also opposed 2017 efforts to repeal the 2010 health care law.

Still, all three Republicans said they’re open to instituting work requirements in Medicaid, which critics say is a means to the same end: saving money via people losing coverage.

A Congressional Budget Office estimate of that provision stated that by implementing the Medicaid work requirements, “the employment status of and hours worked by Medicaid recipients would be unchanged, and state costs would increase,” while federal costs would decrease by $109 billion over 10 years. About 600,000 people could become uninsured, the CBO projected.

“Work requirements — I want to be clear — I’m for,” said Hawley, who said he has a commitment from Trump not to sign a bill that could cut Medicaid benefits. “But beyond that, actual benefit cuts, no, I’m not going to vote for that.”

On the whole, Republicans, including Hawley, have long opposed expanding Medicaid, with state legislators resisting doing so for several years after the 2010 health care law allowed the states the option, even with the federal government picking up 90% of the costs.

But voters feel differently, evidenced by voters in seven states with Republican governors approving Medicaid expansion through ballot initiatives.

“To some extent, the political dynamics we’re seeing on Medicaid are a reflection of the changing Republican political base. … Particularly with the emergence of President Trump, the Republican base has shifted more toward lower-income, working-class people, many of whom rely on Medicaid for coverage,” Levitt said.

Expanding Medicaid in red states has built political salience for the program and made it more difficult for Republican lawmakers to cut it, said Kelly Hall, executive director of the Fairness Project, which helped launch the Medicaid expansion ballot initiative campaigns.

“This is not the last time we’ll have to fight this fight, and next time, we need more Republicans,” Hall said she thought in 2017 when former Sen. John McCain, R-Ariz., blocked the repeal of the health care law with a now-famous thumbs-down motion.

“To have a conversation in 2025 where we’re talking about not just the millions of people who have gotten Medicaid coverage thanks to those ballot measures, but seeing Josh Hawley, who was no friend of the [health care law] for most of his career, now standing and saying, ‘I’m going to oppose Medicaid cuts because of what it means for my state,’ to me, that is so gratifying,” Hall said.

“It really does represent this important notion of when you expand Medicaid anywhere, you help protect it everywhere.”

Enshrined in state constitutions

Missouri is one of the three states, including Oklahoma and South Dakota, where voters not only expanded Medicaid but also enshrined it in the state’s constitution. That means if the federal share of funding for the expansion population were to drop, Missouri would have to find other ways to pay for it.

“A state like Missouri would have to continue with expansion, leading to a huge cost shift to the state,” Levitt said.

Legislators in some states are already toying with the idea of rolling back expansion, fueled by ideological opposition to it but also by fear of how the actions of Congress might impact their budgets.

But in Missouri, bound by the constitution to retain Medicaid expansion, Gov. Mike Kehoe, a Republican, told Hawley any “significant” changes to the federal match rate could blow a $1 billion dollar hole in the state’s budget.

Advocates worry that because the state wouldn’t be able to cut benefits to the expansion population, they might pursue cost-saving measures for other populations that states don’t have to cover under the law, mainly kids, pregnant people and older adults who make more than the federal poverty level. For example, during the 2003 and 2008 recessions, some states cut or froze reimbursement rates to providers and cut “optional” benefits not required by law, like home- and community-based services, dental and vision care.

Rate cuts or freezes could result in providers no longer accepting Medicaid — already an ongoing issue in Missouri and elsewhere.

“People might say we’re not going to cut that, but my concern, especially because of the constitutional amendment in Missouri, are the populations that would be available to cut would primarily be seniors and people with disabilities that are not necessarily part of the expansion population,” said Richard von Glahn, policy director of the left-leaning Missouri Jobs with Justice, which helped organize the state’s Medicaid expansion ballot question.

Optional services covered by Missouri Medicaid include dental, in-home care, pharmacy benefits, medical equipment and more.

In Missouri, 26% of state expenditures go toward Medicaid — one of the highest rates in the nation. Medicaid coverage is widespread in Missouri, covering one-fifth of the population, or 1.3 million people, including 2 in 3 nursing home residents, 1 in 6 Medicare beneficiaries and 40% of births.

Despite the debate about the cost of Medicaid expansion, most expenditures go toward older adults and people with disabilities who are more likely to have higher health care costs.

Hawley said he also wouldn’t support legislation that shifts costs to states.

“We’re a balanced-budget state, which is great. I support that. But that would mean massive benefit cuts,” Hawley said.