Good story from Stateline earlier this week on the national picture in Medicaid expansion. Louisiana is the latest state to expand, becoming the third Southern state to move forward, along with Arkansas and Kentucky. That makes 31 states plus the District of Columbia that have expanded Medicaid. In the 19 refusnik states, an estimated 3 million people are without coverage options because of the red-state holdouts’ refusal to accept billions in federal dollars to expand the program. 

In addition to Louisiana, expanding under the orders of newly elected Democratic Gov. John Bel Edwards, the other piece of news is the election of Tea Party Obamacare opponent Gov. Matt Bevin in Kentucky. Bevin plans to add some Arkansas-style GOP-friendly bells and whistles, which is being treated like a defeat for Medicaid expansion but it’s the opposite: even a Tea Party diehard who campaigned against Medicaid expansion doesn’t have the political will to remove it once its in place. It’s one thing to hold out before the policy is in place. It’s one thing to campaign against it in the abstract. But taking it away — thereby snatching health insurance from hundreds of thousands of citizens and yanking billions of federal dollars out of the health care system? Not even Bevin will do that, which suggests that it’s unlikely that the number of expansion states will go down.  


That’s a relevant question in Arkansas, of course, where the legislature will meet for a special session in April to determine the future of the private option. And Arkansas is a tricky case because of the unique supermajority threshold required in both houses, putting the policy in constant risk even if the politics of taking it away seem impossibly ugly. Stateline notes as much: 

In Arkansas, Republican Gov. Asa Hutchinson, who was elected in 2014, has supported the state’s expansion, but said he was willing to make changes to the program to satisfy critics in the GOP-dominated Legislature. Because of Arkansas unique requirement that at least 75 percent of lawmakers must approve any appropriation and its conservative legislative majority, the future of the state’s Medicaid expansion has been shaky from the start.

Many have compared the slow adoption of Medicaid expansion to the original Medicaid program. Medicaid was signed into law in 1965 and it took seventeen years before the last state, Arizona, opted in. The headline of the Stateline article asks whether Medicaid expansion has reached a “tipping point.” I’d say…not yet! Here’s Stateline: 


At least one other state — South Dakota — is expected to extend Medicaid coverage this year. But in the lead up to the November presidential election, supporters of the ACA aren’t holding out much hope that more states will join in extending Medicaid coverage to more people — although the governors of Alabama, Virginia and Wyoming say they want to, as do key legislators in Maine and Nebraska.

I do suspect there could be another wave after the election. After all, the leading GOP contenders claim they’re going to do away with Obamacare (and the Medicaid expansion) altogether, so state lawmakers might be hesitant to move forward until we know who’s in the White House. Even if that’s just bluster, a new administration, whether Democratic or Republican, will offer up a new negotiating partner for states hoping for unique approaches to expansion like the private option in Arkansas. And then there’s the theory that the political heat around Obamacare will cool off once Obama himself is gone. I’m skeptical on this last point. 

In the end, the momentum seems to be moving in one direction and it’s hard for me to believe that states will continue to refuse billions of federal dollars indefinitely. Expansion is a good fiscal deal for states but that’s especially true in the first three years of the program, when the feds pick up the whole tab. If states opt in a few years from now, they will have foolishly left billions of dollars on the table, accepting a good deal when they could have had a great one. Arkansas was lucky to have lawmakers with more foresight. 


And of course, here are the real stakes: millions of Americans, many of them living in some of the poorest states in the country, do not have access to health insurance because their lawmakers refuse.