Obamacare’s Medicaid Expansion Makes Slow But Steady Progress
The original Medicaid program took 16 years to be adopted in all 50 states, so keep playing the long game on Medicaid Expansion
The pace of the implementation of the Affordable Care Act has been a justifiable source of frustration — especially the foot-dragging by Conservative states on the ACA’s Medicaid Expansion.
Since 2012, when the U.S. Supreme Court gave state officials a choice to take or reject expansion, which would extend Medicaid coverage to everyone in households earning below 138 percent of the poverty line, many state Republican elected officials — egged on by hard-edge ideological groups — have dug in their heels against providing health coverage for their constituents.
As a result, expanding Medicaid in numerous Republican-controlled states has seemed a glacially slow process.
It’s been damaging as well: the 14 states as that haven’t expanded Medicaid as of 2020 have kept an estimated 4.4 million people from gaining health insurance. According to a significant body of research, a lack of insurance is linked to increased mortality; one credible estimate suggests 1 of every 830 individuals without insurance will die due to a lack of coverage, which adds up to an extra 5,300 extra deaths every year in the states that haven’t expanded.
But Rome wasn’t built in a day.
And neither is health policy in the United States.
Even the State Children’s Health Insurance Program (SCHIP) — a wildly popular program with support across ideological and partisan lines, needed three years after its beginning in 1998 to get up and running in every state.
It took 16 years for all 50 states and Washington DC to get a Medicaid program up and running. At the beginning of 1966, when Medicaid first began reimbursing states for expenses, only six states had set up a program. By the beginning of 1967, that had grown to 26 states. Over the next three years, most other states jumped on board.
Alaska and Arizona were the holdouts, with Alaska joining in 1972. Arizona finally created a program in 1982 after more than a decade and a half of ideological trench warfare in which conservatives resisted efforts to expand the social safety net (sound familiar?) before finally agreeing to a create a Medicaid program to prevent the state’s counties — who shouldered the burden of health care for the poor — from going bankrupt.
As figure 1 shows, the progress of the ACA’s Medicaid expansion has been slower, but it is now or will be operating in 37 of the 50 states and Washington DC this year.
However, since we live in a much more polarized time in which strong ideological organizations can play disproportionately powerful roles in limiting the social safety net, the fact that Republican-dominated states like Idaho, Utah and Nebraska have steadily accepted and implemented the Medicaid expansion is still encouraging. Activists embracing alternatives like referenda to bypass recalcitrant Republican-controlled state legislatures has also been exciting to watch.
Another hopeful sign is a “rachet effect” that appears to hold up across both original Medicaid and the ACA’s Medicaid expansion. Once a state gets in the program, they haven’t backed out.
That doesn’t mean that Medicaid isn’t at risk — 2020 and future elections will play a large part in determining whether the program continues to expand or is dramatically cut back. But it does mean that the state-by-state efforts of activists are making a difference.
After all, we may be losing more than 5,000 lives annually because Medicaid hasn’t been expanded everywhere. But as of 2017, Medicaid expansion had insured 12.69 million people who otherwise wouldn’t have had coverage, which translates to more than 15,000 lives saved every year.
That’s quite a satisfying accomplishment for us to dwell on as we keep pushing to expand to the rest of the states. Slow and steady wins the ultimate race — but also remember to celebrate that we’ve already won quite a bit.
