Ever since the Affordable Care Act became law, elections for governor have held more significance when it comes to health insurance benefits because of Medicaid expansion and, more recently, Medicaid work requirements. Whoever occupies the office of governor can shift a state’s landscape on those issues. Three states held gubernatorial elections in November 2019, and the outcomes will impact those states’ Medicaid programs.


In Kentucky on Nov. 5, 2019, Andy Beshear, a Democrat, narrowly defeated the incumbent, Republican Gov. Matt Bevin. Bevin contested the results but conceded Nov. 14.

While governor, Bevin closed Kentucky’s state-run health insurance exchange, Kynect, in 2017 and shifted to the federal platform, HealthCare.gov. Kynect was one of the most successful state-run exchanges in the country, was easy to use, and had strong outreach efforts that promoted exchange and Medicaid enrollment.

In addition, Bevin sought and received a Medicaid work requirement, which would have resulted in beneficiaries losing Medicaid coverage. In January 2018, Kentucky became the first state in the country to receive a Medicaid work requirement, which was blocked by the courts twice, most recently in March 2019.  The work requirement, referred to as “community engagement,” would have required nonexempt adult Medicaid beneficiaries age 19–64 to participate in work activities 80 hours per month. Work activities included employment, education, job skills training, receiving substance use disorder treatment, and community service.

With the election of Beshear, work requirements will become a non-issue in the state, and it is possible Kynect could be resurrected. 


Mississippi also held its gubernatorial election on Nov. 5, 2019.

The state has a Medicaid coverage gap, meaning residents may earn too much to qualify for Medicaid but not enough to qualify for ACA subsidies and credits, which would help residents buy exchange plans.

Two-term Republican Gov. Phil Bryant was ineligible to run for a third term because of term limits. Lt. Gov. Tate Reeves ran for office against Democrat Jim Hood, the state’s attorney general. Reeves won the election with 52.1 percent of the vote, virtually guaranteeing that Mississippi will continue to be a holdout on Medicaid expansion and will continue to seek a Medicaid work requirement.

The state submitted its application to add work requirements for nondisabled adults in January 2018 and resubmitted it in May 2018 to guarantee beneficiaries up to 24 months of Medicaid coverage if they work 20 hours a week, because those impacted by the work requirement likely would have lost their health coverage since their income would make them ineligible for Medicaid. However, the income limit for recipients remains low because Mississippi has not expanded Medicaid eligibility. The state potentially faces an uphill battle to get its work requirement approved.


In Louisiana, Gov. John Bel Edwards, a Democrat, was narrowly re-elected with 51.3 percent of the vote in a runoff election held Nov. 16, 2019. Edwards expanded Medicaid eligibility as called for under the Affordable Care Act on his second day in office in January 2016. Since implementation in June 2016, more than 481,500 individuals across the state have gained coverage.

In January 2018, Gov. Edwards announced plans to seek “reasonable” work requirements for able-bodied adults but stopped when the courts blocked the requirements in Kentucky and Arkansas.

While GOP challenger Eddie Rispone was in favor of keeping the Medicaid expansion, he wanted to freeze enrollment. 

What will 2020 bring?

 Among the 14 states that have not expanded Medicaid eligibility or voted on the issue at the ballot box - Alabama, Florida, Georgia, Kansas, Mississippi, Missouri, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming - 2020 will see state lawmakers introduce bills to expand Medicaid. While nothing is likely to change in most of these states, Kansas and North Carolina are two states to watch.

In Kansas, Democratic Gov. Laura Kelley signed an executive order in September 2019 to establish a committee to make recommendations to guide a bill promoting Medicaid expansion in 2020. Gov. Kelley ran for office on the issue of expansion in 2018, but, despite bipartisan support, Republican leaders blocked her expansion bill.

In North Carolina on June 28, 2019, Democratic Gov. Roy Cooper, who supports Medicaid expansion, vetoed a state budget proposed by the Republican-controlled legislature mostly because of disagreements with Republican lawmakers about Medicaid expansion; lawmakers failed to override the veto. Look for Gov. Cooper and other Democratic lawmakers to champion Medicaid expansion in 2020.

Joyce Caruthers is a senior analyst for Decision Resources Group. Follow her on Twitter @JCaruthersDRG.

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