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.