July 15 — The selection of Indiana Gov. Mike Pence as Donald Trump's running mate gives the presumptive Republican nominee a strong conservative partner with experience in health-care policy, but one who comes with plenty of controversy.
Pence spent a dozen years in the House and has been Indiana's governor since 2012, giving Trump a potential vice president with plenty of political and legislative experience—qualities the New York businessman has often said he was looking for. Pence has the support of religious conservatives because of his efforts to limit abortion in Indiana. He also began trying to defund Planned Parenthood as early as 2007, before it became a popular target of today's congressional conservatives.
But Pence also broke from his party's ideology when he decided to expand Medicaid in Indiana using federal money made available under the Affordable Care Act. His expansion model had a conservative twist with plenty of strings attached for the Medicaid population, but it was ultimately approved by the Obama administration. Some conservatives may consider that a betrayal and an embrace of Obamacare, but Pence can argue that he did what he thought was best for the people of his state.
Trump announced the selection July 15 on Twitter, with a press event set for the weekend in New York.
The Obama administration has already begun to make a point about Indiana's Medicaid expansion. During a July 14 press conference, before the Pence announcement was official, White House press secretary Josh Ernest said Pence has done “important work with the administration to expand Medicaid in his state.”
Reliable Conservative
The vice presidential nominee traditionally doesn't make much of a difference when it comes to presidential voters, but it may prove differently this year, Sabrina Schaeffer, executive director of the Independent Women's Forum in Washington, told Bloomberg BNA July 14.
Voters are looking for someone with gravitas, who is ready and able to step into the shoes of the president, should that become necessary, Schaeffer said. They are looking for a vice president who brings with him a “sense of security” in an election in which polls have shown that many voters view both potential presidential picks as “dangerous.”
The Independent Women's Forum is a non-partisan group that seeks to increase the number of women who value free markets, personal liberty and a limited, constitutional government.
Pence, a “principled conservative,” meets that requirement, Schaeffer said. Trump's conservatism has been questioned, and bringing in someone like Pence may relieve voters who weren't certain exactly where Trump stands on several social issues, she said.
The jury, however, may still be out when it comes to evangelical voters. That group undoubtedly approves of Pence for his ultra anti-abortion stance, but may be turned off by his apparent willingness to compromise on religious liberty concerns.
Abortion
Groups supporting abortion rights assailed the selection of Pence.
“A Trump-Pence ticket could spell out a scary reality for American women and our families,” NARAL Pro-Choice America said in a press release the day before Trump officially picked Pence.
According to NARAL, Pence voted consistently “against reproductive freedom” while serving as a representative in Congress. He repeatedly voted to make abortion illegal nationwide in most cases, to ban some of the most common forms of contraception, to ban stem-cell research and to do away with in vitro fertilization, NARAL said.
Pence also led drives to defund Planned Parenthood and voted to deny abortion coverage in plans offered on health-insurance exchanges, NARAL said.
As governor, Pence signed into law a measure prohibiting abortion coverage in the private insurance market, as well as numerous new restrictions on abortion, NARAL said.
“A Trump-Pence ticket should send a shiver down the spine of women in this country,” Dawn Laguens, executive vice president of the Planned Parenthood Action Fund in Washington, said in statement e-mailed to Bloomberg BNA. “Donald Trump just sent a message to the women of America: your health and your lives are not important.”
“Mike Pence has been on a years-long crusade to prevent women from accessing basic health care services—like cancer screenings, birth control, STD testing and treatment—at Planned Parenthood health centers,” Laguens said. She called an anti-abortion measure Pence signed into law last spring “one of the worst abortion restrictions in the country.”
In late June, a federal court in Indiana blocked the state from enforcing some of those restrictions (127 HCDR, 7/1/16). The U.S. District Court for the Southern District of Indiana said at least one of the measures, which prohibits terminating a pregnancy for any “discriminatory” reason, such as its race, sex or diagnosed disability, almost certainly violates the “categorical right to a pre-viability abortion” recognized by the U.S. Supreme Court in Roe v. Wade, 410 U.S. 113 (1973).
Anti-abortion groups did not respond to Bloomberg BNA's requests for comment.
Religious Liberty
In 2015, Pence signed into law Indiana's Religious Freedom Restoration Act, which allowed Indiana businesses to cite religious freedom as a defense when accused of discriminating against certain individuals, including lesbian, gay, bisexual and transgender people.
Pence, in a Wall Street Journal opinion piece, defended the law as ensuring “that Indiana law will respect religious freedom and apply the highest level of scrutiny to any state or local governmental action that infringes on people's religious liberty.”
Following immediate backlash from corporations, Pence signed a revised version of the law clarifying that it may not be used to discriminate against people based on gender identity or sexual orientation.
In the health-care arena, the federal Religious Freedom Restoration Act has been used to strike down regulations implementing the Affordable Care Act's essential coverage provisions, most notably the provision requiring employers to provide employee health plans that cover contraceptive-related services, as to employers that have strong religious objections to providing the coverage (126 HCDR, 7/1/14).
The Religious Freedom Restoration Act is a “really important issue,” Schaeffer of the Independent Women's Forum said. After Pence signed the revised state law, he was viewed as being “wishy-washy” on religious liberty issues, which might make some evangelical voters uncomfortable, she said. But, Schaeffer said she doesn't believe religious liberty issues are the top concern for most voters.
Other religious liberty issues, however, may come up during the election.
For example, the Supreme Court recently refused to review a decision from the U.S. Court of Appeals for the Ninth Circuit that upheld Washington state pharmacy regulations that the challengers said infringed the conscience rights of pharmacists and pharmacy owners who have religious-based objections to providing drugs they deem to be abortifacients (125 HCDR, 6/29/16).
Pence backed legislation providing strong conscience right protections for health-care workers while in Congress.
Medicaid Expansion
Pence may also find himself in the uncomfortable position of calling for a repeal of the Medicaid expansion he helped to enact.
Trump has put forward a broad health-care plan on his website that includes repealing all of the ACA—including the Medicaid expansion. Trump would also turn Medicaid into a block-grant program.
The House Republican health-care plan, which is partly designed for Trump to adopt if he becomes president, would also repeal all of the ACA's mandates and penalties. Bloomberg Intelligence analyst Brian Rye said Pence is House Speaker Paul Ryan's (R-Wis) best advocate to get that health plan enacted.
Trump hasn't been too interested in focusing on policy details, but “to the extent that there’s an avenue to push a health agenda, [Paul] Ryan has Pence,” Rye said in a July 15 interview. Pence is probably “the most effective advocate for [Ryan's] plan.”
The plan proposes to provide states a choice of either a per capita allotment, or a block grant, for their Medicaid programs beginning in 2019. Depending on their unique set of circumstances, states could choose the block grant option, or otherwise default into a per capita allotment approach. However, experts have said the changes to Medicaid would effectively eliminate the ACA's Medicaid expansion.
Healthy Indiana
Rye said Pence's Medicaid expansion did some damage to his reputation with conservatives trying to repeal Obamacare, but it's not going to matter too much in the general election because of the candidate at the top of the ticket.
“The selection of Pence makes people on Capitol Hill feel better, but I don’t know it will convince voters to vote for that ticket” because of the Trump factor, Rye said. “Expansion is still an issue, but it's overwhelmed by Trump.”
In early 2015, the federal government approved Indiana's version of Medicaid expansion under the Affordable Care Act.
Pence didn't adopt the federal expansion program entirely. Instead, he developed a state-specific program called the Healthy Indiana Plan (HIP) 2.0 (223 HCDR, 11/19/14, 194 HCDR, 10/7/14, 153 HCDR, 8/8/14).
Expanding Medicaid to those earning 138 percent of poverty level was originally a mandatory part of the ACA, but it became optional after the U.S. Supreme Court ruled in 2012 that the federal government couldn't require expansion.
Indiana's complex alternative offers four different Medicaid plans and uses copayments, health savings accounts (HSAs) and premiums to distribute care to different groups. The plan requires most eligible adults earning up to 138 percent of the federal poverty line to pay monthly premiums. When HIP expansion was approved, the state projected the coverage would support an additional 350,000 people who had been uninsured.
The federal government surprised many when it agreed to the plan, which included a provision that would lock beneficiaries who are not “medically frail” and who earn more than 100 percent of the FPL out of the program for six months if they failed to make their premium payment in a 60-day grace period.
HIP includes:
• a basic level plan for individuals earning less than 100 percent of the federal poverty level, who don't pay premiums with limited benefits and preventive care incentives;
• a middle-tier plan requiring beneficiaries to contribute to a health savings account (HSA); and
• an option for beneficiaries to choose a plan sponsored by their employer where they can use their HSA for premiums, cost-sharing and deductibles.
The HIP demonstration was renewed three times between the submission of the plan by the state and federal approval, while state and Centers for Medicare & Medicaid Services officials came to an agreement on how the program would be an alternative to traditional expansion under the ACA.
Several provisions from Pence's original plan were absent from the final CMS-approved waiver on Medicaid expansion, including a requirement that beneficiaries seek employment to be eligible for the plan. Instead, Indiana administers a separate state-funded plan offering assistance in job searches and training.
Careful Praise
Pence has been careful to praise the HIP while avoiding looking like he supports the ACA in any way.
“I have long advocated for the repeal of Obamacare. Yet Republicans have been talking for even more years about reforming Medicaid. That's what we are doing in Indiana,” Pence wrote in a 2014 Wall Street Journal op-ed. “If and when we elect a president and Congress willing to give Medicaid back to the states as a flexible block-grant, I'm confident that states will craft programs—like the Healthy Indiana Plan—that empower low-income Americans to take control of their own health-care choices and provide them access to quality care.”
And in an Indianapolis Star op-ed in January, Pence wrote that “Obamacare is a deeply flawed law with its mandates, taxes and overreaches.”
With the Healthy Indiana Plan, Pence said “Hoosiers are now in the driver’s seat of their health,” not the government.
“Obamacare did not create the Healthy Indiana Plan. HIP existed before Obamacare, and it will exist after Obamacare. Unlike Obamacare, HIP is popular, successful, bipartisan and has demonstrated results,” Pence wrote.
But some are not as convinced by the alternative.
The National Committee to Preserve Social Security and Medicare said in a July 14 statement that Pence's voting record shows he has supported “every form of Social Security, Medicare and Medicaid benefit cut proposed in the past decade.”