March 21
MIAMI, FL - FEBRUARY 13: Hisham Uadadeh walks out of Leading Insurance Agency after enrolling in a health insurance plan under the Affordable Care Act on February 13, 2014 in Miami, Florida. Numbers released by the government showed that about 3.3 million people signed up for health insurance plans under the Affordable Care Act through the end of January. (Photo by Joe Raedle/Getty Images)
Hisham Uadadeh leaves Leading Insurance Agency after enrolling in a health insurance plan under the Affordable Care Act in February. (Joe Raedle/Getty Images)

When the Supreme Court ruled in 2011 that states could refuse to accept the Affordable Care Act’s expansion of Medicaid to everyone earning up to 138 percent of the poverty level, conservatives were as pleased as punch. Here was a way for Republican governors to undermine Barack Obama and the hated Obamacare. Sure, it meant giving up a huge quantity of federal dollars and leaving millions of their own citizens without health insurance. But it wasn’t as though the plight of poor people without coverage was exactly keeping them up nights before.

But some ACA supporters argued that there wasn’t much to worry about. In the end, they said, the money would just be too enticing to pass up. After all, pre-ACA, Medicaid costs were split 50-50 between the states and the federal government, while the feds were to pick up 100 percent of the costs of expansion through 2016, ratcheting down only to 90 percent by 2020, after which it stays at 90 percent. It’s an incredibly good deal for the states: they get the economic boost of a healthier population, they can stop paying for the uncompensated care that happens when sick or injured people without insurance show up at hospitals, and they get it for nothing at first, then pennies on the dollar afterward. Studies from non-partisan observers such as the Rand Corp. showed that even after they start contributing, states will get a net economic benefit. And that’s not even mentioning the moral consideration of taking the opportunity to bring some measure of security to all those people who can’t afford health insurance.

So the thinking was that some of those Republican governors would make noise about it, but eventually they’d come around. After all, it took years for all the states to accept the Medicaid program in the first place after its passage in 1965; one, Arizona, held out for 17 years. And this is a much more favorable deal for the states.

And how are things looking now? At this point, 25 states plus the District have accepted the expansion, and 19 have rejected it. In the other six, debate is ongoing about whether to accept. Lucia Graves at the National Journal argues that opposition is beginning to crack: “The White House hopes unrest in states like Florida, New Hampshire, Nebraska, and Maine will help turn the fight decidedly in their favor. And there’s good reason to think that’s happening.”

I’m a little less optimistic. Yes, there are states where those in favor of the expansion are becoming more vocal. It’s also true that in some places, all you need is one election to change things. In Maine, for instance, both houses of the legislature passed bills to accept the expansion, but fell just short of the supermajority needed to overcome the veto of tea party governor Paul LePage, who swept into office four years ago in a three-way race. If the relatively unpopular LePage loses in November, Maine would be added to the list. And in New Hampshire, the expansion looks to be almost a done deal.

But relatively liberal states in New England are the low-hanging fruit. In a lot of other states, opposition to the ACA will continue for some time to be the clearest way for a Republican politician to establish his or her conservative credentials. If you’re a candidate in Texas or Kansas or Idaho who doesn’t need a single Democratic vote to become governor, you’re not going to do anything to anger your conservative base, and that means promising them that you’ll keep up the fight against Obama.

Might conservative loathing of Obamacare begin to dissipate once Obama himself leaves office in January 2017? Maybe. Ironically, the best thing for the spread of Medicaid expansion might be a Republican in the White House. If the GOP is in charge in the nation’s capital, suddenly it isn’t as important for Republican governors to shake their fists at Washington, and accepting the expansion no longer looks like a favor to a president they hate. The state’s own self-interest could finally win out. That may or may not be enough to make you wish for a Republican victory in 2016.