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As Medicaid expansion advances, ACA scores yet another victory

Heading into the 2022 elections, there were still 12 states that refused to embrace the ACA's Medicaid expansion. Now, we're down to 10 — and counting.


The Affordable Care Act recently celebrated its 13th birthday, and the landmark reform law had plenty to celebrate. Not only have all of the Republican predictions about the failure of “Obamacare” been discredited, but the ACA is clearly effective, popular, and affordable. What’s more, it’s withstood far too many legal challenges, and it no longer has a GOP-imposed target on its back.

As a New York Times headline summarized today, “Obamacare Keeps Winning.”

One of its more notable victories came to fruition this week in Raleigh. The Associated Press reported:

North Carolina Gov. Roy Cooper on Monday signed a Medicaid expansion law that was a decade in the making and gives the Democrat a legacy-setting victory, although one significant hurdle remains before coverage can be implemented, thanks to a Republican-backed provision. At an Executive Mansion ceremony attended by hundreds, Cooper celebrated passage of expansion legislation, which he’s ardently sought since being first elected governor in 2016. It took Republicans in charge of the General Assembly all this time to come around to the idea and agree to offer coverage to more low-income adults, with federal coffers paying for most of it.

The good news comes with a notable caveat: The enrollment start date remains up in the air because the law won’t be enacted until North Carolina’s state budget is done.

Still, the number of states embracing Medicaid expansion stood at 39. Now, it’s 40.

As a result an estimated 600,000 low-income North Carolinians will finally have access to affordable health care.

As for the 10 remaining holdouts, these are the 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 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 assumed, states would obviously want to do the right thing — not only for its low-income citizens, but also for its hospitals. Republicans at the state level may have been far-right ideologues, 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, too.