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National Flag On Stethoscope Conceptual Series - United StatesAs the Healthcare debate continues in Congress, some states are not in a particular hurry to dispense with Obamacare.

Over seven years after the passage of the Affordable Care Act, debate over the law continues to rage. At the federal level the American Healthcare Act, the Republican plan to repeal and replace the ACA, failed after it became apparent that it did not have the votes to pass the House. An overhauled version of that plan is now being worked on in an attempt to secure more votes.

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At the state level, the debate also continues, with resistance slowly but surely beginning to erode. The expansion of Medicaid, one of the cornerstones of the law, and one of the most fervently opposed by the law’s opponents, has begun to pick up momentum after Congress failed to repeal and replace the ACA, according to Governing.

Prior to the ACA, enrollment in Medicaid was limited to certain low-income groups. The ACA expanded eligibility in the federally-funded program to those making up to 138 percent of the federal poverty line. Under the new rules those earning less than $12,060 per year now qualify. However, due to the consequential Supreme Court ruling, National Federation of Independent Business v. Sebelius, which upheld the overall framework of the ACA but required the expansion of Medicaid to be conducted on a state-by-state basis, many states have opted out of this expansion.

To date, 31 states have expanded the program as authorized under the ACA, nearly all of them traditionally blue states. Red states have been either reluctant to do so, or outright refused, many citing fiscal reasons for choosing not to expand. Under the ACA, the federal government will cover 100 percent of the costs incurred by states for expanding Medicaid through 2020; after 2020 it will fund 90 percent with the remaining 10 percent shifting to state budgets.

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Five states, including deep-red Georgia and Kansas are both considering it, though the prognosis for Kansas’ attempt looks grim. Maine, North Carolina and Virginia are also considering expansions, though the prospect for each state does not look likely, as none of the states has a unified government committed to the prospect. The remaining 14 states – Alabama, Florida, Idaho, Mississippi, Missouri, Nebraska, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Wisconsin and Wyoming – have steadfastly refused to expand Medicaid.

In Kansas, lawmakers approved the expansion earlier in March, only to be vetoed by Republican Gov. Sam Brownback. It appears that lawmakers do not have the votes to override the veto, though the final fate of the bill remains unclear. If overridden by the legislature, the expansion would provide coverage for approximately 150,000 low-income Kansans and provide an infusion of cash into the state, which is economically reeling from the cost cutting measures imposed by Governor Brownback and the state legislature in 2012; though it would also threaten to leave the state in a more financially precarious state beginning in 2020. Since passing comprehensive tax cuts in 2012, the state has struggled to meet its current financial obligations including adequately funding schools.

Georgia Republican Gov. Nathan Deal announced that he is open to a compromise with the federal government that would allow the state to expand the program on its own terms, similar to deals made in Indiana and New Hampshire. In Maine, the state legislature has passed Medicaid expansion a staggering five times, only to be vetoed in turn by Republican Gov. Paul LePage every time. This November, the question will face voters, following a successful campaign to get the measure on the ballot.

As time continues to press on, so does opposition to the ACA and the expansion of Medicaid. Adam Searing, associate professor at Georgetown University’s Center for Children and Families, has an eye on four states in particular – Florida, Georgia, North Carolina and Texas. If one of those states expands Medicaid, then the oppositional dam breaks.

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