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(Cross Posted at The Makeshift Academic)

Since the Supreme Court made the Affordable Care Act’s Medicaid Expansion optional, many state legislatures and governors; well at least many of them dominated by Republicans, have loudly declaimed that they will not accept the expansion.

 Proponents of the expansion – meaning those of us who understand public policy and/or have a soul – have been bitterly disappointed in the states which are preventing millions of people from getting access to health insurance.

 But let’s have a bit of historical perspective here.  The original Medicaid was a voluntary program as well and it took a bit of time for the states to get their act together. When federal matching funds became available in January of 1966, a grand total of six states had programs set up, as this Kaiser Foundation brief shows (see page 6). By the end of the year, 26 states had signed up.

Coincidentally, when New Hampshire expands its Medicaid program in July, 26 states will have signed up for the expansion (plus DC).

For the original program, 37 states had jumped on board by the end of 1967, 41 by the end of 1968 and 48 by Jan. 1 1970. (Alaska joined in 1972 and Arizona finally dragged itself into the program in 1982)

The point is that we tend to forget that it took more than a decade for all states to get into the Medicaid program. The beauty (sarcasm alert) of American federalism is that instead of merely having to get things enacted through an inefficient national legislature and executive, we often have to get them enacted through 50 inefficient regional legislatures and executives as well. Give it some time – often  states will see what’s working in other states and try to pick up on programs (or free money) that work. The Children's Health Insurance Program is another example -- it took three years for all 50 states to get on board after the federal government created the program in 1998.

This analysis doesn’t necessarily mean that the ACA’s Medicaid expansion will be picked up as quickly – political parties weren’t as polarized in the late 1960s as they are today, which means that opposition to the latest expansion may be more entrenched, even when the results are crystal clear.  And in any case, delays to extending the program will result in thousands of unnecessary deaths.

However, we shouldn't despair -- Medicaid wasn't built in a day; so there's no reason to expect the expansion to become universal in a year either. The important thing is to keep grinding forward and organizing to gain political power to make states do the right thing for their residents.

Originally posted to Fake Irishman on Sun Apr 27, 2014 at 07:36 AM PDT.

Also republished by Obamacare Saves Lives and Community Spotlight.

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Comment Preferences

  •  Thanks for the perspective (9+ / 0-)

    Medicaid expansion is already making swing states and some Red states swingier in our direction. That and the success of the first ACA Open Enrollment period have already turned around predictions that Democrats would lose the Senate. As more good news comes in, our political prospects will get steadily better, as Bill Kristol pointed out in opposing Hillarycare in 1993.

    The sum of all GOP fears

    Being able to hammer heartless Republicans isn't enough. We still have to GOTV.

    Back off, man. I'm a logician.—GOPBusters™

    by Mokurai on Sun Apr 27, 2014 at 08:03:25 AM PDT

  •  Excellent and you are correct (6+ / 0-)

    We must have patience and if you live in one of these hell hole red neck states like I do, consider moving to one that has a little more compassion.

  •  Thank you for this "history" reminder. It (3+ / 0-)
    Recommended by:
    jazzmaniac, Fake Irishman, BMScott

    gives one perspective & hope.

    Well written; well done Fake Irishman!

  •  I understand the Canadian system also took many (3+ / 0-)
    Recommended by:
    BMScott, GMFORD, third Party please

    years to develop to the point it is now. Individual province buy-ins and all...

    "real" work : a job where you wash your hands BEFORE you use the bathroom...

    by chimene on Sun Apr 27, 2014 at 12:37:56 PM PDT

  •  Nicely done (2+ / 0-)
    Recommended by:
    BMScott, third Party please

    I remember so well that great series you did on the financing of ACA.  I've been following you and I also hotlisted this one for the link to that outstanding Kaiser historical review.

    I took a quick scan of that Kaiser paper and I wish they had included more of the discussion about why some states were slower to get on board with Medicaid.  It couldn't possibly be as toxic as some of the opposition today.  I suspect AZ had some careful calculations to do with that state becoming more of a retirement destination.

    But the good news for us is that as far as I've heard there is no deadline for any state by which the extension must be accepted.  One by one, they'll get on board.  A few as low hanging fruit when state changes from R to D, a few more as some states adopt the Arkansas model, etc...


    I'm not liberal. I'm actually just anti-evil, OK? - Elon James White

    by Satya1 on Sun Apr 27, 2014 at 01:08:14 PM PDT

    •  Thanks! (0+ / 0-)

      I'm glad some on is getting something out of this. (actually, it has helped me land a job interview or two, believe it or not)

      I noticed that with the Kaiser report too -- I wonder if it was active resistance or just various stages of getting their act together. There didn't seem to be too much rhyme or reason to who jumped on first. Incidentally, I suspect they will get on board like you say -- one at a time.  Arizona picked up Medicaid in 1982 -- when a coalition of counties and hospitals finally convinced the state to get on board. Might be a good diary for one of us to write sometime -- the political dynamics behind how Arizona finally joined the program (under a waiver no less)

  •  Elections have consequences. (0+ / 0-)

    McAuliffe's win in Virginia last year means that there is a chance to expand it there, although it may require a government shutdown if the special session dealing with expansion isn't done by July 1st (the legislative session ended March 8th with the Senate passing a private-option expansion and the House passing a budget without Medicaid).

    If Maine, Pennsylvania and Florida flip our way this year, these states might expand Medicaid (assuming the legislatures follow). Montana might do so this year through a ballot initiative.

    It will take some pressure, but hopefully the "South's new lost cause" will be over soon.

    •  If we get Le Page, Maine goes for sure (1+ / 0-)
      Recommended by:

      A Dem in PA's governorship will make a straightforward AR waiver pretty easy (Corbett is holding it up with his job search requirement).  Florida's leg will stay GOP, but picking up a few seats and a Crist governorship will probably simplify the problem.

      And thanks for the update on VA -- I didn't realize how close they were. What was the vote in the Senate? -- party line or did several GOPers break ranks?

      •  GOPers broke ranks. (0+ / 0-)

        The Senate is evenly split 20-20, so the "private option" brought a few on board. It passed with three Republican votes in favor.

        Right now it is a game of chicken, and it will likely continue so until July 1st approaches. House negotiators say that "they want to negotiate Medicaid separately from the budget" but that of course means "we never want to expand Medicaid."

  •  I assume (0+ / 0-)

    inefficient is a code word for "incompetent bigots".

    "the northern lights have seen queer sights, but the queerest they ever did see was the night on the marge of Lake Lebarge when I cremated Sam McGee" Robert Service, Bard of the Yukon

    by Joe Jackson on Tue Apr 29, 2014 at 09:58:22 AM PDT

  •  We have a stronger moral argument in this case. (0+ / 0-)

    This is great historical perspective, but the ACA was designed to give everyone access to health insurance. All citizens. The earlier changes didn't have that feature. This time, it's more directly about fairness as well as compassion.

    In these rejection states, we the people, through our government, are now stepping in to make sure that everyone can afford health insurance- except for those below the poverty line. Make 101% of the FPL, you get subsidies. Make 99%, no subsidies. Imagine that situation applied to any other area where we get help from our government to get by- access to education, for example. It's too straightforward in its unfairness. Too easy to fix.

    This was not the intent of the ACA.  The only argument the other side really had against Medicaid expansion was that the ACA would fail. Since it isn't collapsing, I hope they very quickly realize how awful of a position this is for them, and take action to expand Medicaid before they are associated with the tragic and unjust impacts of not doing so.

    I agree, we can expect that more states will join the fold over time. And for our side, the fundamentals of this issue are very strong.

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