Kathleen Sebelius wasn’t President Obama’s first choice to run the Department of Health and Human Services and oversee the passage and implementation of health care reform. But after Sen. Tom Daschle (D-SD) dropped out, Obama tapped the two-term Kansas governor and former state insurance commissioner. Sebelius didn’t have much D.C. experience, but had an impressive track record of working across the aisle as a Democratic governor in a red state.
And while the united GOP opposition to health legislation eventually overwhelmed any goodwill Sebelius had built up within the Republican party and the rocky rollout of Obamacare has come to dominate the discussion of her tenure as secretary, that bipartisan quality proved essential to the implementation of the law. Sebelius leaves the office having enrolled some 10 million people in health care coverage. This was only possible because she convinced numerous Republican lawmakers in bright red states to extend health care coverage to the poorest Americans. No one is talking about it, but it is her biggest and most impressive achievement as secretary.
In the aftermath of the Supreme Court’s 2012 decision invalidating Obamacare’s compulsory Medicaid expansion, most Republican-controlled states refused to extend health care coverage to residents below 133 percent of the poverty line. But Sebelius traveled the country, urging Republican governors to reconsider. As of today, eight GOP-controlled states have approved expansion — in no small part because of the flexibility Sebelius and her team provided.
To convince political opponents like Iowa Gov. Terry Branstad (R) or Arkansas’ Republican-controlled legislature to adopt one of Obamacare’s most significant coverage provisions, HHS approved alternative proposals that allowed states to use federal funding to cover their low-income uninsured populations with private insurance. Similarly, Sebelius permitted Oklahoma to continue using federal Medicaid dollars to subsidize private health insurance for low-income workers and extended to Indiana a one-year extension of its pilot Medicaid program, which provides coverage for low-income residents. Michigan’s Republican Gov. Rick Snyder also signed a Medicaid expansion bill into law after receiving a federal waiver for cost-sharing provisions for Medicaid beneficiaries from the federal government.
The flexibility extended beyond Medicaid. Sebelius and her team convinced red states to form partnership health care exchanges in which the federal government and the state would share responsibilities in running the marketplaces. They routinely presented GOP governors with information on all other state models and waivers, assuring them that they could customize reform to their specific state needs. As a result, several Republican-dominated states bucked the national party and chose to run their exchanges either on their own, or in collaboration with HHS.
The solutions became politically tenable to Republican lawmakers because they could claim that they were covering their residents on their own terms, using unique state-tailored solutions that rejected the “one-size-fits all” prescription of Obamacare. Sebelius’ policy flexibility provided conservatives with enough political cover to implement key parts of the law.
“It’s helpful that Secretary Sebelius has been a former governor and she understands the uniqueness of the states, the challenges we all face, which are different,” said Gary Herbert, the GOP governor from Utah, joining several other Republicans who have publicly praised her willingness to meet with hostile governors and answer their questions.
Last month, in an interview with USA Today, Sebelius predicted that all GOP-controlled legislatures will eventually expand Medicaid in their states, closing a coverage gap that has left 4.8 million poor Americans without coverage. “It not only would bring more people into the health care system, but it would dramatically reduce unpaid medical costs,” she said. If the states do comply, it will be in no small part because of the bipartisan legacy she left behind.