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Red-State Medicaid Expansions — Achilles’ Heel of ACA Repeal?

people health insurance


Since Medicaid eligibility was expanded under the Affordable Care Act (ACA), 12 million Americans have gained insurance coverage through the program as well as improved access to health care and prescription medicines. Personal medical debt has decreased as well, and hospitals have seen their uncompensated care burden — for patients with no ability to pay — drop by $10 billion. The Obama administration estimated that approximately 24,000 lives have been saved each year by the ACA’s coverage expansions.

Despite these accomplishments, repeal of the ACA, including the Medicaid expansion, appears likely. With support from the Commonwealth Fund, Benjamin D. Sommers and Arnold M. Epstein of the Harvard T.H. Chan School of Public Health looked at the Medicaid expansion from the consumer’s viewpoint in a New England Journal of Medicine “Perspective.”

What the Study Found

The authors looked at four states: Arkansas and Kentucky, which have expanded coverage; Texas, which has not; and Louisiana, which expanded coverage in June 2016. They asked low-income adults in all four states about the effect the ACA has had on their lives. In the three expansion states, twice as many respondents said they had been helped by the law than hurt by it. In Texas, more respondents thought it had hurt them than helped them.

The authors also analyzed the data by race. Whites in Kentucky and Arkansas — a reliably conservative group overall — said the law had helped, rather than harmed, them. The strongest predictor of positive attitudes toward the law were residing in an expansion state and having Medicaid or ACA marketplace coverage (as opposed to being uninsured).


In states that have embraced Medicaid expansion despite their residents’ political leanings, the ACA has made a positive difference that people can see and understand, the authors find. In the congressional debates to come, a key question will be how conservatives and moderates in states that have seen historic reductions in their uninsured numbers will approach the decision to repeal the Medicaid expansion.

Publication Details



Mary Mahon, Former Vice President, Public Information, The Commonwealth Fund

[email protected]


Benjamin D. Sommers and Arnold M. Epstein, “Red-State Medicaid Expansions—Achilles’ Heel of ACA Repeal?,” New England Journal of Medicine, published online Jan. 25, 2017.