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Why it matters that another state has embraced Medicaid expansion

As Medicaid expansion takes effect in a 40th state, the developments are dramatic, both substantively and politically.

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By any fair measure, Affordable Care Act is having a good year. As regular readers know, the ACA is working well; it’s more affordable than ever; it’s about as popular as it’s ever been; it’s withstood far too many legal challenges; and many Republicans are scared to talk about it.

As a New York Times headline summarized, as the landmark reform law celebrated its 13th birthday, “Obamacare Keeps Winning.”

As WUNC, the public radio affiliate in North Carolina, reported this morning, the winning streak includes a breakthrough in the Tar Heel State.

Medicaid expansion goes live in North Carolina today, opening up the government-run health insurance program to hundreds of thousands of low-income adults. The state’s Republican-controlled legislature had for years rejected expansion, part of the Affordable Care Act that passed during President Obama’s administration and derided by opponents as “Obamacare.” This year, however, the Tar Heel state changed course.

As a substantive matter, this will make an enormous difference for many families: An estimated 600,000 low-income North Carolinians will finally have access to affordable health care.

It also contributes to a larger pattern: For a while, the number of states embracing Medicaid expansion through the ACA stood at 39. Now, it’s 40.

As a political matter, the developments are well timed: Just this week, Donald Trump announced plans to go after the Affordable Care Act, and if he were to take office and succeed, breakthroughs like these would be undone.

Indeed, it was a point President Joe Biden seemed eager to emphasize in a written statement on the developments in North Carolina. “Despite this progress, MAGA Republicans still want to get rid of the Affordable Care Act, just like my predecessor tried and failed to do repeatedly,” the Democrat said. “There are 40 million people who get their health insurance through the Affordable Care Act and repealing the law would put their care at risk. Repealing the Affordable Care Act means that states, including North Carolina, wouldn’t be able to offer care through Medicaid expansion.”

As for the holdouts that have not yet accepted Medicaid expansion, there are 10 remaining states: Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming. Any chance they’ll soon come around? As The Washington Post recently reported, the odds aren’t great.

...North Carolina may be the last of the Medicaid expansion holdout states to reverse course for a while. Supporters of extending the safety net coverage to hundreds of thousands more low-income adults have repeatedly run into Republican resistance in the 10 states that have long refused the Obamacare program — and another victory isn’t imminent.

When the U.S. Supreme Court initially upheld the Affordable Care Act’s constitutionality, the court’s majority delivered some bad news to health care advocates: Medicaid expansion, the justices concluded, had to be optional, not mandatory under federal law.

In policy circles, many assumed this wouldn’t be too big a deal. After all, they thought, states would obviously want to do the right thing — not only for its low-income citizens, but also for its hospitals and state budgets. There are plenty of far-right ideologues and Republicans at the state level, the assumption held at the time, but they could do arithmetic. No state would choose to be so foolish as to voluntarily reject Medicaid expansion, right?

A decade later, 10 states still won’t budge. That said, North Carolina’s breakthrough came as something of a surprise, so health care advocates have reason to keep trying in the holdout states, hoping that common sense might yet prevail in Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming.

This post updates our related earlier coverage.

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