Tag Archives: states

On Medicaid money, GOP has win-or-lose proposition for states

New England’s bucolic countryside looks much the same on either side of the Connecticut River separating Vermont from New Hampshire. But Medicaid beneficiaries are far better off in Vermont.

Vermont generously funds its Medicaid program. It provides better benefits, such as dental care, and pays doctors more than New Hampshire’s program does. That brings more doctors into the program, giving enrollees more access to care.

New Hampshire has twice Vermont’s population, but Vermont spends almost as much on Medicaid and covers more enrollees. Under the complicated formulas that set federal funding, Vermont’s substantial investment helps it capture nearly as much aid from the government as New Hampshire gets.

States’ policies differ about who or what to cover in Medicaid, and those decisions have led to historical variances in how much federal money they receive. House Republicans’ effort to shrink federal Medicaid spending would lock in the differences in a way that favors those already spending high amounts per enrollee.

“Republicans are finding out why changing Medicaid is so hard and why the easiest thing to do is to do nothing given the substantial variation in federal spending across states,” said John Holahan, a health policy expert with the nonpartisan Urban Institute.

Here’s why.

Medicaid, the national health program for low-income people that covers about 1 in 5 Americans, is 60 percent funded by the federal government and 40 percent by states. Total spending in 2015 was about $532 billion, according to the latest official data.

Federal funding is open-ended, which means the government guarantees states it will pay a fixed rate of their Medicaid expenses as spending rises.

Those matching rates are tied to average personal incomes and favor the lowest-income states. Mississippi has the highest Federal Matching Assistance Percentage — 76 — while 14 wealthy states, including New York and California, get the minimum 50 percent from the federal government.

But state Medicaid spending varies significantly, too, and that influences how much federal money each receives to fund its program. State policies about how generous benefits should be and how much to pay doctors and hospitals account for those differences.

GOP leaders want to give states a set amount of money each year based on the number of Medicaid enrollees they had in 2016, a formula known as per-capita caps.

A per-capita system would benefit high-spending states already receiving relatively rich allotments from the government, the Urban Institute said in a paper last September.

According to its estimates, if the system were in effect this year, Vermont would receive $6,067 per enrollee — one of the highest allotments in the country — while New Hampshire would get the least, just $3,084 per enrollee.

Per-capita caps would limit the government’s Medicaid spending because it would no longer be on the hook to help cover states’ rising costs. But caps also would shift costs and financial risks to the states and could force them to cut benefits or eligibility to manage their budgets.

“It would present a huge problem,” said Adam Fox, a spokesman for the Colorado Consumer Health Initiative, an advocacy group.

Under the GOP bill, federal Medicaid funding to states would be adjusted annually based on a state’s enrollment and medical inflation. But that would not be enough to keep up with rising Medicaid spending per enrollee, which would force states to put up more of their money or scale back the program, the nonpartisan Congressional Budget Office said March 13.

Other analyses of the GOP plan have reached the same conclusion.

Since 1999, however, the average annual growth rate in Medicaid spending per enrollee has risen more slowly than medical inflation, according to MACPAC, the Medicaid and CHIP Payment and Access Commission, which advises Congress.

Republicans argue that overhauling federal Medicaid spending as they propose would hold down federal costs while giving states more leeway to run their programs as they see fit. “This incentive would help encourage efficiencies and accountability with taxpayer funds,” House Speaker Paul Ryan wrote last June in his white paper, A Better Way.”

Rep. Greg Walden (R-Ore.), chairman of the powerful House Energy and Commerce Committee, which has oversight of health care matters, sounded a similar note at a press conference in Washington, D.C., when the GOP plan was announced. “I think it’s really important to empower states and to put Medicaid on a budget,” he said.

But Fox argued the opposite would happen under a per-capita system — instead of gaining more control over their Medicaid programs, states would not be able to meet their needs because they’d have fewer dollars to decide how to spend, he said.

Bill Hammond, director of health policy for the nonpartisan Empire Center for Public Policy in New York, said House leaders’ decision to tie future Medicaid funding to medical inflation could help mute concerns that funding wouldn’t keep up with rising costs, but would not address the fairness issue of giving some states higher per-capita amounts than others.

“If a low-spending state decides it wants to spend more money on paying hospitals and doctors or adding more benefits, they would have a harder time doing that without breaking the federal cap,” he said.

Medicaid advocates in New Hampshire are worried because their state has few alternatives to make up for a loss in federal funding. New Hampshire lacks an income or sales tax.

“There is a tremendous amount of fear among families here as Republicans try to dismantle the ACA,” said Martha-Jean Madison, co-director of New Hampshire Family Voices.

Published under a Creative Commons license. Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.

Republican wins could lead to amending U.S. Constitution

The November election put Republicans in full control of a record number of state legislatures around the country, a level of power that gives the party an unprecedented opportunity: change the U.S. Constitution.

Republicans already control Congress, the White House and more governors’ offices than they have in nearly a century. But it’s the state legislatures that could produce lasting change.

The GOP now holds numerical majorities in 33 legislatures, one shy of the two-thirds required to initiate a convention on constitutional amendments. There is no credible talk of using that power for amendments on hot-button social issues, such as banning abortion or gay marriage. But conservatives have a list of bread-and-butter governing issues they would like to see enshrined in the Constitution.

One, to require a balanced federal budget, is already approaching the level of support that would trigger a convention. Beyond that, a major state-level push is planned during 2017 for a constitutional convention that could also consider amendments to impose term limits on members of Congress and rein in various federal powers.

President-elect Donald Trump has pledged support for an amendment on congressional term limits.

“The possibility of constitutional change is in the air,” said law professor Jeffrey Rosen, president and CEO of the National Constitution Center in Philadelphia, a nonprofit museum that is hosting academic debates and symposiums about the efforts to amend the Constitution.

The U.S. Constitution has been amended 27 times since it was ratified in 1788, and its Article V spells out two ways to propose amendments. By a two-thirds vote of each chamber, the U.S. House and Senate can refer an amendment to the states. Or two-thirds of the state legislatures can request that Congress call a convention of the states.

Both scenarios require three-fourths of the states — or 38 — to ratify an amendment before it takes effect.

If the supporters of a balanced budget amendment succeed, it would be the first time in the nation’s history that states initiated the process. That scenario has become more likely as a result of the November election.

It takes 34 states to trigger a convention for constitutional amendments, meaning a unified Republican push would need the help of only a few Democrats in a single state to reach the mark.

“The overwhelming success of one political party at the state level is something of real constitutional significance,” said Akhil Reed Amar, a constitutional law professor at Yale University.

Every state except Vermont has some sort of balanced budget requirement, according to the National Conference of State Legislatures. The U.S. government does not, but not everyone agrees that’s a problem. During recessions, for example, federal government spending can help drive the economy even if it means spending at a deficit.

Twenty-eight state legislatures already have approved measures calling for a convention to propose a federal balanced budget requirement, although they use a variety of terms that could raise legal questions about whether they all count toward the threshold.

Organizers at the nonprofit Balanced Budget Amendment Task Force have lined up sponsors in nine additional Republican-led legislatures — Arizona, Idaho, Kentucky, Minnesota, Montana, South Carolina, Virginia, Wisconsin and Wyoming — with the goal of reaching the two-thirds threshold in 2017.

But Republican control is no guarantee of success.

A Wyoming measure calling for a convention on a balanced budget amendment was shelved in 2015 after the state Senate altered it to make it contingent on assurances that Wyoming would not see a reduction in federal revenue.

Montana’s Republican-led House overwhelmingly defeated a resolution calling for a convention on a balanced budget amendment when it last met in 2015. Opponents expressed fears of a “runaway convention” during which delegates might propose all types of possible amendments.

Similar fears have thwarted past attempts at passing a balanced budget amendment. The movement peaked at 32 states when Missouri passed a resolution calling for a convention in 1983, then dipped to about half that as numerous states rescinded their resolutions. The tally began growing again after Republicans swept into control of many capitols in 2010.

The possibility of a convention dominated by delegates from a single party is “alarming,” said Carolyn Fiddler, a spokeswoman for the national Democratic Legislative Campaign Committee.

“There are no rules. They can just throw out the whole Constitution if they want to,” Fiddler said. “It’s the wildest of Wild West situations.”

Supporters of a balanced budget amendment hope to allay such fears by convening this coming summer in Nashville, Tennessee, to propose rules and procedures for a future convention on constitutional amendments. They contend a convention is unlikely to veer off into contentious issues such as abortion and gun rights because amendments ultimately will need bipartisan appeal to win ratification from 38 states.

The mere possibility of a state-initiated convention has been enough to prompt Congress to action in the past. With states just shy of the two-thirds mark in 1912, Congress instead wrote its own amendment requiring senators to be elected by a vote of the people rather than through state legislatures. The states then ratified the amendment.

But Congress has repeatedly fallen short of the two-thirds vote needed to refer a balanced budget amendment to the states. The last time both chambers tried was in 2011.

During the past three years, eight states have passed resolutions calling for a convention that would go beyond a balanced budget amendment to include other fiscal restraints, term limits for Congress and federal officials, and unspecified restrictions on federal power. Though still far from the two-thirds threshold, supporters of those causes believe the Republican rise to power could help their movement grow rapidly.

“With the election and things that have happened, it provides really a once-in-a-lifetime opportunity to restore critical structural checks in our constitutional system,” said Utah state Rep. Ken Ivory, a Republican attorney.

Ivory was elected in September as the presiding officer of a simulated convention of the states designed to demonstrate that the method of proposing constitutional amendments actually can work. Among those present at the event was law professor Randy Barnett, director of the Center for the Constitution at Georgetown University.

“Amending the Constitution is always a longshot, no matter how you go about it,” Barnett said. But if 34 states — including 33 Republican ones — call for such a convention, “it would be very difficult for the Congress to stop that.”

A tip sheet for workers and workplaces where pot is legal

Changing marijuana laws aren’t necessarily making weed more welcome in the workplace.

For now, many employers seem to be sticking with their drug testing and personal conduct policies, even in states where recreational marijuana use is now permitted. Others are keeping a close eye on the still evolving legal, regulatory and political environment.

Voters in California, Massachusetts, Maine and Nevada voted Nov. 8 to approve the use of recreational marijuana, joining Colorado, Washington, Oregon and Alaska, where it had previously been legalized. (A recount of Maine’s close result is scheduled.) More than two dozen states have medical marijuana programs.

But the drug is still against federal law.

A closer look at what it all means for workers and businesses:

CAN MY EMPLOYER STILL TEST ME FOR POT?

Bottom line: You can’t come to work high. You can still be drug tested. And you can still be fired — or not hired — for failing a drug test even if you’re not the least bit impaired at work.

All the states with legalized recreational pot have exemptions for workplace drug policies.

In Massachusetts, for example, the law includes language stating that “the authority of employers to enact and enforce workplace policies restricting the consumption of marijuana by employees” is not changed.

“Yes, you may be able to have (marijuana) at home, but that doesn’t mean it’s OK in the workplace,” said Edward Yost, an HR specialist with the Society for Human Resources Management.

WHAT ABOUT WORKPLACE SAFETY?

Advocates for marijuana legalization said it was never their intention to compromise safety, a central reason offered by employers for drug testing.

“We don’t want anyone to come to work impaired on any drugs,” said David Boyer, campaign manager for the ballot initiative in Maine.

A 2013 survey by the employee screening firm HireRight found 78 percent of employers conducted drug tests either randomly, as a condition of employment, after accidents or for some combination of those reasons.

The federal government requires drug testing for some workers, including truck drivers and others in transportation.

Quest Diagnostics, which performed nearly 11 million laboratory-based drug tests for employers in 2015, said the percentage of tests coming back positive has shown a modest increase in recent years. Nearly half of all positive tests showed evidence of marijuana use.

CAN I GET FIRED EVEN IF I’M NOT HIGH?

THC, the psychoactive chemical in cannabis, can stay in a person’s system for days or even weeks, experts say — long after the buzz has subsided.

“It’s the equivalent of firing somebody who drank a glass of wine on Friday evening and then came to work on Monday,” said Tamar Todd, legal director for the Drug Policy Alliance, who believes employers should reconsider zero-tolerance policies in light of changing laws and attitudes.

A number of efforts are underway to develop an accurate method, akin to the Breathalyzer for alcohol, to measure actual marijuana impairment. Such a test might be useful not only for employers, but also for police and prosecutors trying to determine what constitutes driving under the influence of marijuana in states where recreational pot is legal.

WHAT SHOULD COMPANIES DO?

At a minimum, companies should review their current polices, make sure their managers are trained and make clear to employees that marijuana use on or off the job can still land them in trouble, said James Reidy, a New Hampshire-based attorney who advises clients around the country on drug testing issues.

Tina Sharby, chief human resources officer for an Easter Seals affiliate with about 1,700 employees in New England, said the organization, which provides services for people with special needs, is monitoring the evolving legal and regulatory environment but is sticking with its drug testing protocols for now.

“We have a drug-free workplace policy, and we believe that the current policy we have is effective,” Sharby said.

But drug testing and zero-tolerance rules can also make it difficult for businesses with a need to recruit young professionals who may harbor more liberal attitudes toward pot.

“We have ski industries out here, and if they really took a hard line on marijuana use, they would have to shut down,” said Curtis Graves, information resource manager for the Colorado-based Mountain States Employers Council.

After Colorado became the first state to legalize recreational marijuana in 2012, surveys showed an uptick in workplace drug testing, Graves said, but that trend has begun to shift in the other direction.

“Employers who have a zero-tolerance policy maybe shouldn’t apply that to non-safety sensitive workers, because if they do testing on them, they run the risk of inviting an invasion of privacy claim,” suggested Amanda Baer, a Boston-area attorney who specializes in labor and employment issues.

WHAT DO THE COURTS SAY?

Adding to the uncertainty is the scarcity of legal precedent in states that have legalized recreational marijuana. But several cases involving employees with permits to use medical marijuana have reached the courts, and most have been decided in employers’ favor.

The most widely cited case is a 2015 Colorado Supreme Court that upheld Dish Network’s firing of a disabled man who used medical marijuana and failed a drug test. The court ruled that a state law barring employers from firing workers for off-duty behavior that is legal did not apply because pot remains illegal under federal law.

Similar rulings have been issued in other states including California, Montana and Washington.

As medical marijuana programs become more common even in states where recreational pot remains outlawed, some companies have begun to weigh accommodations for workers with permission to use marijuana for an existing health condition.

 

2018 outlook: Trouble ahead for Senate Democrats?

A look at the Democratic senators facing re-election in 2018 from states where President-elect Donald Trump won or nearly won on Election Day:

States Trump won, with margin of victory according to early and unofficial returns:

Tammy Baldwin, Wisconsin, Trump by 1 percentage point.

Sherrod Brown, Ohio, Trump by 9.

Bob Casey, Pennsylvania, Trump by 1.

Joe Donnelly, Indiana, Trump by 19.

Heidi Heitkamp, North Dakota, Trump by 36.

Joe Manchin, West Virginia, Trump by 42.

Claire McCaskill, Missouri, Trump by 19.

Bill Nelson, Florida, Trump by 1.

Jon Tester, Montana, Trump by 21.

 

States Democrat Hillary Clinton won narrowly:

Angus King, independent who aligns with Democrats, Maine, Clinton by 3.

Amy Klobuchar, Minnesota, Clinton by 2.

Tim Kaine, Virginia, Clinton by 5.

Election Day from coast to coast: Key races in every state

 

Much more is at stake on Election Day than the White House. State by state, district by district, neighborhood by neighborhood, candidates and campaigners are making their last pitch for Congress, state legislatures, governor’s offices, ballot questions, judgeships, city councils and lots more.

A nationwide look at important, interesting and occasionally odd matters that go before voters today:

ALABAMA

Alabama voters must decide on 14 statewide constitutional amendments affecting everything from funding for state parks and the age of public officeholders to beer. Yes, beer. The Alabama Alcoholic Beverage Control Board wants to require brewers to report the name, address, age and phone number from anyone who purchases beer at one of the state’s craft breweries for off-premises consumption.

ALASKA

Republican U.S. Sen. Lisa Murkowski is up for re-election, and the race has drawn not one but three foes: Democrat Ray Metcalfe, independent Margaret Stock, and Joe Miller, who upset Murkowski in the 2010 GOP primary only to then lose the general election in a historic write-in campaign. This time Miller is running as a Libertarian.

ARIZONA

Eight years after losing his bid for president, Republican U.S. Sen. John McCain is running for re-election. McCain has publicly struggled with whether to support GOP presidential nominee Donald Trump, who called McCain a loser and criticized him for being captured during the Vietnam War. Marijuana is on the ballot; voters could legalize the drug for recreational use by adults. Minimum wage could rise to $12 an hour by 2020 under a separate ballot measure. Metro Phoenix Sheriff Joe Arpaio, the self-proclaimed toughest sheriff in America, is fighting for his job after a criminal indictment stemming from his immigration patrols.

ARKANSAS

Arkansas could become the first Southern state to legalize medical marijuana, although a similar proposal lost by less than 30,000 votes a year ago, out of 1.3 million votes cast. Republicans are expected to hold all four of Arkansas’ U.S. House seats. Democrats are fielding a candidate in only one district.

CALIFORNIA

Democratic U.S. Sen. Barbara Boxer’s retirement creates a rare open seat, and for the first time in the modern era, no Republican will be on the ballot. Thanks to California’s unusual primary system, in which the two top finishers from the June primary advance to the general election, voters will decide between two Democrats _ state Attorney General Kamala Harris and U.S. Rep. Loretta Sanchez. The statewide ballot has a whopping 17 propositions, the most on a single ballot since March 2000. There’s a measure to legalize recreational marijuana and one requiring porn actors to wear condoms. Voters will weigh in twice on the death penalty. One measure would repeal capital punishment while another seeks to speed up the process.

COLORADO

Democratic U.S. Sen. Michael Bennet is running for re-election against a tea party-aligned opponent, conservative Darryl Glenn, who has struggled to raise funds after national party leaders refused to endorse his candidacy. In a hotly contested House race, Republican U.S. Rep. Mike Coffman is facing a challenge from Democratic state Sen. Morgan Carroll in suburban Denver. The chief ballot questions would allow medical aid in dying and create a universal health care system within the state.

CONNECTICUT

The five Democrats who make up the state’s U.S. House delegation face re-election, including Rosa DeLauro, the longest serving member in the group who is seeking a 14th term. Dr. William Petit, whose wife and two daughters were murdered in a 2007 home invasion, is running as a Republican for the Legislature against state Rep. Betty Boukus, an 11-term Democrat who heads the powerful House bonding subcommittee.

DELAWARE

Voters will elect a new congressional representative and a new governor, while Republicans are hoping to end years of Democratic rule in the General Assembly by regaining control of the state Senate. Democratic U.S. Rep. John Carney Jr. is making a second run for governor against Republican state Sen. Colin Bonini. Democrat Lisa Blunt Rochester and Republican Hans Reigle are vying for the state’s lone U.S. House seat.

DISTRICT OF COLUMBIA

Voters in the nation’s capital will decide whether they want their city to become the 51st state. The measure, backed by Mayor Muriel Bowser, should pass easily, but that’s probably as far as it goes. Congress would need to approve any such change and Republicans are unlikely to go along with it. With registered Democrats outnumbering Republicans by 12-1 in the city, statehood would tip the balance in the U.S. Senate with two more Democrats.

FLORIDA

Florida voters will decide whether Republican U.S. Sen. Marco Rubio gets a second term. They’ll also pick at least eight new U.S. House members after districts were redrawn to comply with the state constitution, and will cast ballots on legalizing medical marijuana. Rubio faces Democratic U.S. Rep. Patrick Murphy, while ex-Republican Gov. Charlie Crist hopes to revive his political career _ now as a Democrat _ in a race against Republican U.S. Rep. David Jolly in a St. Petersburg-area district.

GEORGIA

Democrat Jim Barksdale and Libertarian Allen Buckley are challenging Republican U.S. Sen. Johnny Isakson, who seeks a third term. Barksdale, who owns an Atlanta investment firm, gave $3.5 million toward his first political campaign, but has struggled to get momentum against the well-known Isakson. Georgia voters also will decide on a constitutional amendment allowing the state to take over low-performing schools.

HAWAII

Voters in Honolulu must make two separate choices after U.S. Rep. Mark Takai died in office: Someone to fill his seat for the remaining two months of his term, and someone to represent the district for the next two years. Voter confusion could lead to two different people winning the same seat, to serve two different terms. In heavily Democratic Hawaii, the only state Senate seat held by a Republican, Sam Slom, could flip. That would make Hawaii the first state in the nation to have a one-party legislative body since 1980.

IDAHO

Republicans will dominate at the top of the ticket, leaving an open seat on Idaho’s Supreme Court as the most competitive race. Twin Falls attorney Robyn Brody and Republican state Sen. Curt McKenzie are in a tight, nonpartisan race.

ILLINOIS

Illinois is home to one of the most closely watched U.S. Senate races in the country, with Republican incumbent Mark Kirk and Democratic U.S. Rep. Tammy Duckworth. Kirk, a first-term senator, is considered one of the more vulnerable Republicans, and polls have indeed shown Duckworth with a comfortable lead. Wealthy Republican Gov. Bruce Rauner has spent record amounts on down-ballot races in hopes of tilting the Democrat-leaning Legislature toward the GOP so he can press his own policy agenda in second half of his term.

INDIANA

With Republican Gov. Mike Pence on the national ticket as Trump’s running mate, the governor’s office is up for grabs. And this is another state with a U.S. Senate race that will be crucial to determining party control. A former governor and U.S. senator, Democrat Evan Bayh, wants to return to the Senate and faces Republican U.S. Rep. Todd Young. Democrats are hoping to gain enough seats in the General Assembly to break the current Republican stranglehold.

IOWA

Republican Charles Grassley is seeking a seventh U.S. Senate term and trying to retain a seat his party has held since 1957. Democrats are optimistic that their candidate, Patty Judge, can break that winning streak, given her previous elections to statewide office as agriculture secretary and lieutenant governor. Two of Iowa’s four U.S. House races are expected to be especially competitive.

KANSAS

Democrats are seeking to cut into Republican majorities in both houses of the Legislature and oust more allies of term-limited GOP Gov. Sam Brownback. Conservatives and abortion opponents are seeking to remove four Kansas Supreme Court justices in hopes of giving Brownback a chance to remake the court ahead of major abortion and school funding rulings.

KENTUCKY

Voters will decide whether to send Republican U.S. Sen. Rand Paul, who made an early run for the presidency, back to Washington for a second term. His Democratic opponent is Lexington Mayor Jim Gray. Voters also will determine whether the only legislative chamber in the South still controlled by Democrats remains so. Republicans need to pick up four seats to win a majority in the Kentucky House for the first time since 1920.

LOUISIANA

Two dozen _ that’s right, two dozen _ candidates are vying for an open seat in the U.S. Senate after incumbent David Vitter decided not to seek re-election. One of them is white supremacist David Duke, who is not among the top-tier candidates in polling. Because no candidate is likely to get the 50-percent-plus-one majority needed to win outright, the top vote-getters will head to a Dec. 10 runoff that could end up determining which party gains control of the U.S. Senate for the next two years.

MAINE

Mainers will decide whether to make marijuana legal for everyone over age 21. Maine is one of nine states considering ballot questions on pot legalization for recreational or medicinal use. Another initiative would require background checks before the sale or transfer of firearms between people who aren’t licensed dealers. And one would boost the hourly minimum wage from $7.50 to $12 by 2020.

MARYLAND

Voters will pick a replacement for the popular Barbara Mikulski, who is retiring after 30 years in the U.S. Senate. U.S. Rep. Chris Van Hollen, a seven-term Democrat, is running against Kathy Szeliga, minority whip in the state House of Delegates. She has sought to portray Van Hollen as an insider of dysfunctional Washington. Baltimore will choose a new mayor.

MASSACHUSETTS

Massachusetts voters will also vote on marijuana legalization, as well as a proposed expansion of charter schools. There are a handful of congressional contests, with Democratic U.S. Reps. Richard Neal, Niki Tsongas, Joe Kennedy, Stephen Lynch and William Keating all facing challengers.

MICHIGAN

It’s the Democrats’ last shot to disrupt the GOP’s agenda or Republicans will lead the Legislature all eight years of GOP Gov. Rick Snyder’s tenure. At least a dozen GOP-held House districts _ half with incumbents, half open due to term limits _ will determine which party secures the minimum 56 seats needed. Democrats have targeted two GOP-held U.S. House districts, while two spots on the Michigan Supreme Court represent the most significant statewide races.

MINNESOTA

A trio of competitive congressional races takes top billing in Minnesota. Democratic Rep. Rick Nolan will try to fend off a rematch challenge from Republican Stewart Mills to hang on to a northeastern Minnesota district that has been a liberal stronghold for decades. The result has been one of the most expensive House elections in the country. Republican Rep. Erik Paulsen will be defending his suburban Minneapolis seat, while the two parties jostle over another suburban district that opened with a top Republican’s retirement.

All 201 state House and Senate seats are on the ballot in an election to determine legislative majorities. Voters will also decide whether to hand off legislators’ power to set their own pay to an independent council.

MISSISSIPPI

All four of Mississippi’s U.S. House members _ three Republicans and one Democrat _ are up for re-election. All are likely to prevail. Four of the nine state Supreme Court seats will also be filled, as will four of 10 seats on the state Court of Appeals.

MISSOURI

Missouri voters will decide whether to send U.S. Sen. Roy Blunt to a second term, or choose Democratic challenger Jason Kander instead. It’s a race that will help decide party control of the Senate, and polls have indicated a toss-up for months. Meanwhile, Missouri’s contentious campaign for governor has been the nation’s most expensive. Republican newcomer Eric Greitens, a former Navy SEAL, has campaigned largely on his military record, while Attorney General Chris Koster has endorsements from the Missouri Farm Bureau and National Rifle Association, which typically support Republicans.

MONTANA

Popular Democratic Gov. Steve Bullock is up for a second term in the conservative-leaning state against software entrepreneur Greg Gianforte, who spent more than $5.6 million of his own money on his campaign. Incumbent U.S. Rep. Ryan Zinke is seeking to hold off a determined challenge from Democrat Denise Juneau to maintain a two-decade Republican lock on Montana’s sole House seat. Pot is also on the ballot, with a measure that would loosen many of the restrictions imposed on the state’s medical marijuana program with a 2011 state law that limited marijuana providers to three patients each.

NEBRASKA

Nebraska voters have the opportunity to reinstate the death penalty and reverse last year’s decision by the Legislature. The citizen-led ballot measure has triggered millions in campaign spending. In one of the country’s most competitive congressional races, Republicans are looking to defeat first-term Democratic U.S. Rep. Brad Ashford, who promotes himself as a champion of bipartisanship. His opponent, Don Bacon, is a retired Air Force brigadier general who is running as a Washington outsider.

NEVADA

Nevada is home to one of the most expensive U.S. Senate races in the country, featuring lots of TV ads about the seat being vacated by Democratic leader Harry Reid. The race is between U.S. Rep. Joe Heck, a Republican, and Democrat Catherine Cortez Masto, a former Nevada attorney general trying to become the first Latina U.S. senator. Recreational marijuana is also on the ballot, raising the possibility of pot shops springing up near the Las Vegas Strip.

NEW HAMPSHIRE

New Hampshire is a presidential swing state, and home to a tight U.S. Senate contest between Republican incumbent Kelly Ayotte and Democratic Gov. Maggie Hassan. It’s one of a half-dozen races that could help determine which party controls the Senate. Two members of the U.S. House, Republican Chris Sununu and Democrat Colin Van Ostern, are vying to replace Hassan as governor.

NEW JERSEY

One of the nastiest U.S. House races in the country this year has pitted a Republican incumbent, Rep. Scott Garrett, against Democrat Josh Gottheimer. In a district that stretches from wealthy New York City suburbs to the state’s rural northwestern corner, the two candidates have called each other liars and engaged in a war of words and accusations to rival the presidential candidates. New Jersey voters will also decide on a proposed expansion of casino gambling.

NEW MEXICO

There’s little suspense at the top of the ticket, with all three U.S. House incumbents expected to be re-elected, so Republicans are focused on defending their narrow majority in the state House. The party took over in 2014, ending 60 years of Democratic control. The criminal conviction and resignation of former Secretary of State Dianna Duran in 2015, for embezzlement and money laundering related to her gambling addiction, has opened that office. The race is between Democrat Maggie Toulouse Oliver and Republican state lawmaker Nora Espinoza.

NEW YORK

Voters will decide whether the Republican Party maintains control of the state Senate or Democrats secure total control of state government. The outcome is likely to come down to a handful of competitive races on Long Island and in the Hudson Valley.

NORTH CAROLINA

As a focal point in battles over transgender rights and voter ID laws, North Carolina may be the state where social and ideological divisions are the most defining this election year. Republican Gov. Pat McCrory is in a tight race against Democrat Roy Cooper, the state’s attorney general. Former state Rep. Deborah Ross is presenting a strong challenge to incumbent Republican U.S. Sen. Richard Burr in one of the most closely watched Senate races.

NORTH DAKOTA

As this state’s energy- and agriculture-dependent economy falters, voters will choose a new governor to lead it through increasingly troubled financial times. But with Republican Doug Burgum a heavy favorite in this reliably red state, five ballot measures may be of most interest. Among the most-watched will be a measure that would make it legal to possess up to 3 ounces of marijuana for medical purposes.

OHIO

Early on, former Gov. Ted Strickland looked like one of the Democrats’ best bets to flip a U.S. Senate seat in his party’s favor. He’s running again Republican incumbent Sen. Rob Portman. Then outside groups spent more than $50 million to beat Strickland, who also lost key union endorsements and was up against a formidable voter outreach and turnout effort by Portman. Now the seat looks pretty safe for the GOP.

OKLAHOMA

Oklahoma voters will be watching a ballot issue that targets the state’s chronically low teacher salaries and one that would enshrine the death penalty in the state constitution, even as executions remain on hold after mistakes in two recent lethal injections.

OREGON

A Republican is threatening to win statewide office for the first time in many years, in a battle for secretary of state that is the hottest in Oregon. Democrat Brad Avakian is running ads saying his GOP rival is “extreme like Trump.” Republican Dennis Richardson has racked up endorsements from numerous newspapers and even from two prominent members of Avakian’s own party.

PENNSYLVANIA

Since 1948, no Democrat has won the White House without winning Pennsylvania. There’s also a hot U.S. Senate race between Democratic challenger Katie McGinty and Republican incumbent Pat Toomey, who is among the most vulnerable Republicans as the GOP struggles to retain its majority. Spending on that campaign is on track to hit $140 million.

RHODE ISLAND

Voters in Rhode Island, a state that has seen its share of political corruption, will decide whether to expand the authority of the state’s ethics commission. They’ll also be asked whether to allow a new casino.

SOUTH CAROLINA

Republican U.S. Sen. Tim Scott , the South’s first black senator since Reconstruction, is running for his first full term. He was appointed to the seat in 2013 following the resignation of Sen. Jim DeMint, then won election to the final two years of that term. Democrat Thomas Dixon, a community activist and pastor, is challenging him. Then there’s Democrat Dimitri Cherny, whose platform includes colonizing the moon and Mars in case the Earth becomes uninhabitable. He’s challenging Republican U.S. Rep. Mark Sanford, the ex-governor whom voters sent back to Congress in 2013.

SOUTH DAKOTA

The main suspense is likely to be the fate of 10 ballot questions on topics ranging from public campaign funding to payday loan interest rates.

TENNESSEE

Democrats are hoping to chip away at vast Republican majorities in the state Legislature by focusing on urban areas, while the GOP is seeking to stamp out the last vestiges of Democratic support in rural parts of the state.

TEXAS

Texas’ only competitive congressional race looks to be the rematch between Republican U.S. Rep. Will Hurd and former Democratic Rep. Pete Gallego in a district that sprawls from San Antonio to suburban El Paso, including 800-plus miles of U.S.-Mexico borderlands. Hurd unseated Gallego in 2014. The entire Texas House also is up for election, along with 16 of the state Senate’s 31 seats. Regardless of the outcomes, both chambers will remain Republican-controlled.

UTAH

The independent campaign of Evan McMullin has made Utah suddenly relevant in presidential politics. If the former CIA operative, a Mormon, can win the state and claim its six electoral votes, it could upend Donald Trump’s chances for the White House end five decades of reliably voting for the Republican nominee.

VERMONT

This state, considered among the most liberal in the country, may well elect a Republican governor. That race pits Lt. Gov. Phil Scott, a Republican, against former state Transportation Secretary Sue Minter, a Democrat.

VIRGINIA

Barbara Comstock, a first term GOP congresswoman, is trying to fend off a serious challenge from Democrat LuAnn Bennett. Trump’s unpopularity in northern Virginia has loomed large in the race, with Bennett trying to tie Comstock to the presidential nominee. In the crowded race for mayor of Richmond, the front-runner is Joe Morrissey, a former state lawmaker who went to jail for having sex with his then-17-year-old receptionist, who is now his wife

WEST VIRGINIA

Republicans are hoping to ride on the coattails of an expected strong showing for Trump, who has promised to put coal miners back to work. In the governor’s race, Democrat Jim Justice, a billionaire coal and agriculture magnate, faces Bill Cole, the state Senate president. In the state auditor’s race, Democrat Mary Ann Claytor is vying to become the first African-American statewide officeholder in West Virginia history.

WASHINGTON

Democratic Gov. Jay Inslee is seeking a second term. He faces Republican Bill Bryant, a former Seattle port commissioner who says Inslee has mismanaged the state’s mental health system and failed to fund K-12 education as mandated by the state Supreme Court. Six initiatives are on the statewide ballot, including raising the minimum wage to $13.50 an hour by 2020 and imposing a carbon emission tax on certain fossil fuels.

WISCONSIN

It’s 2010 all over again in Wisconsin’s U.S. Senate race. This time, Republican Sen. Ron Johnson is the incumbent and former Democratic Sen. Russ Feingold is the challenger. Johnson argues that having been fired once by voters, Feingold does not deserve to be sent back. But Feingold says Johnson has not led on the issues Wisconsin voters care about and should not be given a second term.

WYOMING

Republican Liz Cheney is heavily favored to win Wyoming’s only seat in the U.S. House, which was formerly held by her father, former Vice President Dick Cheney. Her opponent, Democrat Ryan Greene, works for an oilfield services company. Wyoming voters also will decide whether to allow the state to invest potentially billions more in the stock market, changing a state law that limits investments.

3 in 10 gay men have HIV in some Southern cities

Three out of every 10 gay or bisexual men in several Southern cities have been diagnosed with HIV, three times the national rate, according to a study about how common HIV infections are in metro areas.

The study echoes other research that reported higher rates of HIV diagnoses in the South but it is the first to look at how common HIV diagnoses are in these men by city.

“For the first time, we can see not only the numbers, but the proportions,” said Dr. Jonathan Mermin of the U.S. Centers for Disease Control and Prevention.

The report found 21 of the 25 metro areas with the highest levels of HIV diagnosis in gay and bisexual men were in the South.

HIV was diagnosed in about three in 10 gay and bisexual men in El Paso, Texas; Augusta, Georgia; and Baton Rouge, Louisiana.

In Jackson, Mississippi, the rate was four in 10, the highest in the nation.

According to the report, about 11 percent of gay and bisexual men had been diagnosed living with an HIV infection nationwide during the time covered by the study.

Emory University researchers produced the new numbers using national counts of HIV diagnoses in different communities. Lacking good census counts of sexually active gay and bisexual men, they used data from previous studies to calculate how many men had sex with other men.

In its look at metro areas, the study counts only those who have tested positive for HIV.

Because many HIV cases are not diagnosed, those numbers don’t reflect how common HIV infections really are in each area. It’s also not clear what factors may vary from city to city that might explain differing rates.

Still, while the largest total numbers of gay and bisexual cases are in large cities like New York and Los Angeles, this research gives a better understanding that the chance of encountering partner living with HIV is far greater in some smaller communities, some experts said.

The research was released through an obscure publication, the Journal of Medical Internet Research. CDC officials described the work as important and useful in deciding how to target HIV prevention funds.

On the Web

The CDC.

The journal.

Baldwin pushes for Medicaid expansions with new bill

New reform introduced by U.S. Sen. Tammy Baldwin would ensure that states that opt to expand eligibility for Medicaid can access the same federal funds as states that expanded the health care program before 2014, under the Affordable Care Act.

“I support this legislation because it is my hope it will point our state in the right direction,” Baldwin, a Democrat from Wisconsin, said in a news release.

The Affordable Care Act has provided federal financial support for states to expand Medicaid programs to provide health care coverage to individuals up to 138 percent of the federal poverty level.

The federal government, under the ACA, pays the cost of expansion for the first three years for the states that enrolled in 2014 and phases down to a 90 percent match rate for the sixth and subsequent years.

In a lawsuit over the expansion program, the U.S. Supreme Court ruled that states could opt-in or opt-in and 19 states — mostly those with Republican governors — opted out.

Republican Gov. Scott Walker has refused to expand Medicaid eligibility in Wisconsin and instead he shrunk the BadgerCare program.

Baldwin said the governor has put “politics ahead of progress and taken our state in the wrong direction,” kicked Wisconsinites off their coverage and created a coverage gap.

She said she hoped the States Achieve Medicaid Expansion Act of 2016 would provide the incentive for states to opt-in and expand Medicaid programs, as well as assist the seven states that expanded after 2014.

“In the states that haven’t expanded Medicaid, many adults living near the poverty level are now unable to afford health care,” said Jon Peacock, research director of the Wisconsin Council on Children and Families.

He said existing law makes expanding Medicaid a good deal but the SAME Act would create an even better deal. “It would be fairer to give all the states the same incentive to close a gap in affordable coverage for adults near the poverty level,” Peacock said.

Studies show states that expanded Medicaid eligibility saw direct and indirect benefits in job growth, earnings growth, increased gross state product, increased state and local revenues and reduced uncompensated care and hospital costs.

In an analysis released last year, the Kaiser Family Foundation estimated the economic impact of expanding eligibility in Wisconsin would be $1.3 billion and the creation of 10,500 jobs.

“Congress should pass this bill. The president should sign. And Gov. Walker and the Legislature should … expand BadgerCare to cover 83,000 more people and save state taxpayers more than a billion dollars over the next 10 years,” said Mike Bare of Community Advocates Public Policy Institute.

Baldwin introduced the bill along with Democrats Mark Warner of Virginia, Debbie Stabenow and Gary Peters of Michigan, Claire McCaskill of Missouri, Jon Tester of Montana, Tim Kaine of Virginia and independent Angus King of Maine.

Court to weigh Obama’s immigration orders

The raging political fight over immigration comes to the Supreme Court on Monday in a dispute that could affect millions of people who are in the United States illegally.

The court is weighing the fate of Obama administration programs that could shield roughly 4 million people from deportation and grant them the legal right to hold a job.

Among them is Teresa Garcia of suburban Seattle, who has spent 14 years in the United States illegally after staying beyond the expiration of her tourist visa in 2002.

She already has gotten much of what she wanted when she chose not to return to her native Mexico. Her two sons are benefiting from an earlier effort that applies to people who were brought here illegally as children. Garcia’s 11-year-old daughter is an American citizen.

“That’s why I come, for the opportunity for the children and because it is much safer here,” the 45-year-old Garcia said in an interview with The Associated Press.

Now, she would like the same for herself and her husband, a trained accountant who works construction jobs. Neither can work legally.

“To have a Social Security number, that means for me to have a better future. When I say better future, we are struggling with the little amount of money my husband is getting for the whole family. It makes for stress every day. We struggle to pay for everything,” Garcia said.

The programs announced by President Barack Obama in November 2014 would apply to parents whose children are citizens or are living in the country legally. Eligibility also would be expanded for the president’s 2012 effort that helped Garcia’s sons. More than 700,000 people have taken advantage of that earlier program, Deferred Action for Childhood Arrivals. The new program for parents and the expanded program for children could reach as many as 4 million people, according to the nonpartisan Migration Policy Institute.

Texas, Wisconsin and 24 other states sued to block the new initiatives soon after they were announced, and lower courts have ruled in their favor. The programs have never taken effect.

The states, joined by congressional Republicans, argue that Obama doesn’t have the power to effectively change immigration law. When he announced the measures 17 months ago, Obama said he was acting under his own authority because Congress had failed to overhaul the immigration system. The Senate had passed legislation on a bipartisan vote, but House Republicans refused to put the matter to a vote.

“Fundamentally, we don’t think the president has the statutory or constitutional authority to issue these executive actions,” said Texas Attorney General Ken Paxton.

House Republicans told the court that Obama is claiming the power “to decree that millions of individuals may live, work and receive benefits in this country even though federal statutes plainly prohibit them from doing so.”

The administration and immigration advocates say the immigration orders are neither unprecedented nor even unusual. Rather, they say, Obama’s programs build on past efforts by Democratic and Republican administrations to use discretion in deciding whom to deport.

The court’s last major immigration decision, the 2012 case Arizona v. U.S., lends some support to this view.

“A principal feature of the removal system is the broad discretion exercised by immigration officials. Federal officials, as an initial matter, must decide whether it makes sense to pursue removal at all,” wrote Justice Anthony Kennedy. “Discretion in the enforcement of immigration law embraces immediate human concerns. Unauthorized workers trying to support their families, for example, likely pose less danger than alien smugglers or aliens who commit a serious crime.”

The administration and its supporters said the challenged programs do not offer blanket protection, but depend on case-by-case reviews. The protection from deportation also would be temporary, for three years.

“It’s not permanent status, not a green card, not a path to citizenship. It doesn’t get you a ticket into a voting booth. At best, it’s a tolerated presence,” said Angela Maria Kelley, an immigration expert at the Center for American Progress.

The programs also could be revoked by the next president, as the Republican contenders have promised. That might leave people who have provided the government with information about themselves in greater peril of being deported.

Immigration advocates acknowledged that some people might not be willing to raise their hands until they know the outcome of the election.

The Supreme Court case might not even address the issue of executive authority if the justices determine that Texas and the other states don’t have the right to challenge it in federal court. Such a resolution, which could attract support from both liberal and conservative justices, could enable the court to sidestep the potentially divisive details over immigration and avoid a 4-4 tie following Justice Antonin Scalia’s death in February.

A decision in favor of the administration would allow the programs to take effect in the waning months of Obama’s presidency. A loss or even a tie vote would block them for the foreseeable future.

Garcia said she is eager to apply for the relief Obama offers if it’s made available.

Garcia said she volunteers in the local schools teaching Spanish to children, providing translation for interactions between parents and the schools and working on the school district’s strategic planning effort. But she has had to turn down offers of a paying job with the school system.

Armed with the Social Security number she so desires, Garcia said, “I would work starting right now.”

A decision in U.S. v. Texas, 15-674, is expected by late June.