Red-State Medicaid Expansions - Achilles' Heel of ACA Repeal?

derided by its opponents as the monolithic “Obamacare,” the ACA is a multifaceted law with several distinct components — subsidized health insurance exchanges, individual and employer mandates, regulations of the individual insurance market including a defined package of essential benefits, and Medicaid expansion. While opposition to several of these elements remains nearly unanimous among conservatives — in particular, the mandates and an approach to federal regulation perceived as onesize-fits-all — the picture is more nuanced when it comes to the underlying expansion of insurance, particularly through Medicaid. Separate from ongoing ideological debates over the law, evidence is mounting on the benefits of Medicaid expansion. In the waning days of the Obama administration, the White House Council of Economic Advisors published a report describing the ACA’s accomplishments,1 many of which stem from the Medicaid expansion: 12 million of the 20 million people who have gained coverage through the ACA have done so through Medicaid. Access to primary care and treatment for chronic conditions have increased, and rates of skipping medications to save money have decreased.1-3 Medicaid expansion has led to as much as a $1,000-per-person reduction in medical debt sent to collection, and hospitals have seen their uncompensated-care burden drop by $10 billion.1 Perhaps most strikingly, the White House estimated — on the basis of extrapolations from prior research on the 2006 Massachusetts health care reform — that approximately 24,000 lives have been saved each year by the ACA’s coverage expansion. Although 19 states have declined to implement the Medicaid expansion, this feature of the law has seen more bipartisan support at the state level than most other aspects of the ACA. More specifically, 13 states won by Donald Trump in the 2016 presidential election have opted into the ACA’s Medicaid expansion since 2014, and 16 expansion states are currently led by Republican governors. Recent statistics from the Centers for Medicare and Medicaid Services indicate that in states that voted for Trump, 4.2 million more people were enrolled in Medicaid as of August 2016 than in 2013. In fact, some of these states, such as West Virginia and Kentucky, have experienced among the largest Red-State Medicaid Expansions — Achilles’ Heel of ACA Repeal?