The State Where Obamacare Is Working

Arkansas managed to insure hundreds of thousands of people by expanding Medicaid. Can it be a model for the country?

Arkansas Governor Mike Beebe had a multi-tiered sort of problem: He’s a Democrat in a state controlled by a Republican legislature. In a year when states are charged with implementing a potentially life-saving provision of the healthcare law. One that is highly unpopular among many conservatives.

Arkansas has the third lowest median household income in the country—$38,413—and last year, a quarter of its adult population was uninsured. But by using federal funds made available under Obamacare, the state had the option to expand Medicaid, the government insurance program for the poor, and thus cover about 220,000 additional Arkansans.

The expansion would cost the state relatively little. It would allow poor people to see doctors, and it would reduce the amount of uncompensated care—services doctors don’t get paid for because the patient is too poor to afford the treatment. But Republican lawmakers were nonetheless wary, and the state requires a three-quarters majority for the type of bill that would authorize the expansion.

“How do you go about getting to 75% when the majority are Republicans, many of whom ran against the ideological issue of Obamacare?” Governor Beebe told me. “It was a mountain some thought couldn’t be ascended.”

First, a little background. (You can skip the next four paragraphs if the Medicaid expansion kerfuffle is old news to you.)

Medicaid is a state-based program that, before The Era of Obamacare, mostly only covered kids, moms, and pregnant women. In its original form, the Affordable Care Act hinged on a state-by-state expansion of Medicaid for people who can’t afford health insurance on the newly created exchanges (so, for people making about $15,800 a year or less). The idea was that the federal government would pay for the new Medicaid enrollees entirely until 2016, and gradually taper down the federal subsidy to 90 percent of the new costs in future years. In general, the expansion is seen as a pretty good deal for the states.

But the 2012 Supreme Court case made the expansion optional for states, throwing a wrench into the Obama administration’s plan to get all of the nation’s poor covered through Medicaid. Most estimates show that states who expand Medicaid could reduce their uninsured populations by around 50 percent or more.

So far, 24 states have opted not to expand Medicaid the way the ACA wants them to. To conservatives, their resistance is seen as a bulwark against an ever-increasing entitlement system. To liberals, it’s viewed largely as, well, a middle finger to the Obama administration: Most of the states have Republican governors or predominantly Republican legislatures, and even though the expansion would be largely paid for by the federal government, accepting it could seem like an acknowledgement of the healthcare law’s legitimacy.

Now, nearly eight million people are left without health coverage because they live in these non-expanding states, and it’s an especially heavy burden on large cities, which are home to a disproportionate share of uninsured, indigent people, as my colleague Emily Badger reported.

The New York Times recently reported on Willie Charles Carter, a Mississippi man who doesn’t qualify for the state’s Medicaid program because he has no dependent children. The free clinic where he goes for medical care is scheduled to close soon due to lack of funding, and this is his strategy for getting healthcare after that point:

“I’m scared all the time,” he said. “I just walk around here with faith in God to take care of me.”

To make matters even more depressing and racially thorny, almost every state in the Deep South rejected the expansion, as this map of states that aren’t doing the expansion, based on estimates from late last month, from the Advisory Board Company, shows.

Advisory Board Company

But eventually, Arkansas found a way.

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Olga Khazan is a staff writer at The Atlantic, where she covers health.

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