Mary Ellen Klas

The iconic image of former Republican Arizona Sen. John McCain giving the thumbs down in a crucial 2017 vote to repeal Obamacare still annoys Donald Trump.

“We’re gonna fight for much better health care than Obamacare,’’ the former president told supporters in Iowa, earlier this month. “Obamacare is a catastrophe. Nobody talks about it. You know, without John McCain, we would have had it done.”

But facts can be inconvenient things, and since that pivotal vote in Trump’s first year in office, there might not have been a lot of talk about the Affordable Care Act, but there’s been some significant action.

Ten years after the U.S. Supreme Court ruled that states’ participation in the ACA marketplace must be voluntary, 40 states and Washington D.C. have agreed to expand Medicaid. The decision allows them to extend the government-subsidized health-insurance plan to working families and individuals who make too much to qualify for traditional Medicaid and don’t have employer-provided health insurance.

But Republicans who spent years vowing to repeal and replace the landmark health-reform law have all but abandoned their anti-Obamacare rhetoric, particularly those who now know that the repeal Trump seeks would hurt a key constituency he needs in his bid to return to the White House – rural voters. Consider:

• A record 20 million people had enrolled in the health-care marketplace to obtain the subsidized insurance policies by the annual deadline last week, nearly twice as many as in 2017, according to the Centers for Medicare & Medicaid Services, and 2 million of them were in rural areas.

• In seven of the states where Republican governors refused to expand Medicaid and the issue was put on the ballot, voters overwhelmingly approved it, underscoring its widespread popularity.

• And, as a final blow to the longshot chances of invalidating the ACA, in 2021 the Supreme Court dismissed a lawsuit brought by the Trump administration and several GOP governors and attorneys general.

Under the law, states that allow all non-elderly people within 138% of the federal poverty level to enroll in Medicaid are reimbursed by the federal government for 90% of the additional cost. 

The federal government has tried to entice the holdout states. In 2021, under the American Rescue Plan, the Biden administration offered another 5% federal match for two years if states adopted the expansion. North Carolina, Missouri, Oklahoma, and South Dakota all joined the bandwagon.

Of the 10 states that have yet to expand coverage — Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming — seven are in the South, where there has been a sustained influx of investment and economic development, but low household income and generational poverty persist. 

Southern states continue to have communities with the most economic hardship in the nation, with 13% of their residents living in poverty, particularly in rural areas and among communities of color. A 2023 report published by the Urban Institute estimates that if the 10 holdouts expanded their Medicaid enrollment, 2.3 million fewer individuals would be uninsured and the greatest gains in coverage would be among non-Hispanic Black Americans, at 43.2%, and among non-Hispanic White Americans, at 29.2%.

Of course, the expansion will increase both federal and state budgets, but it could lower costs overall. As Kody Kinsley, North Carolina’s secretary of health and human services, said recently, when people show up to the emergency room to get health care and hospitals “can’t pay for the person that they’re providing the care to, they’re gonna increase the prices for everybody else that walks in the door.”

Hospitals have long advocated for expanding Medicaid but the impact of treating the uninsured is being dramatically felt in rural America. Of the states that haven’t expanded Medicaid, many of them also are on the list of states with the highest number of rural hospital closures since 2005: Alabama, 5; Florida, 8; Kansas, 9; Georgia, 10; North Carolina, 10; Tennessee, 11; and Texas, 29.

What business wants to move its plant or employees into a town that has no health care? North Carolina, another state with a booming economic development outlook, figured that out last year. 

Democratic Gov. Roy Cooper persuaded North Carolina’s Republican legislative leaders to take the federal government’s offer of a $1.8 billion bonus over two years. In exchange, North Carolina hospitals would cover the state’s 10% share of expenses through increased assessments on their health-care systems.  The agreement is not only expected to create new health-care jobs, but it will provide an additional $8 billion in federal money to help the state reimburse rural hospitals.

This year, the Georgia state legislature, led by Republican House Speaker Jon Burns and Appropriations Committee leaders in both chambers, also started talking about expanding Medicaid in return for restricting hospital certificate of need regulations, concluding that the legislative trade-off would be a boost for rural areas. 

The longstanding Republican argument against Medicaid expansion has been that they don’t want states to shoulder more health-care coverage because it’s another entitlement that adds to the national debt and there’s no guarantee the federal government will keep the spigot flowing. But Republicans have provided no realistic alternative to the ACA, and studies show the long-term benefits of moving from emergency room care to preventive care is morally right, and fiscally smart — for both states and hospitals.

We’re now at a pivot point. The Affordable Care Act is here to stay. Just as January winter turns to March thaw, the holdout states will inevitably come around. It’s time they do it now and reap the rewards. And if Trump has any concern for his rural constituency, he should abandon his futile promise of repeal.

Mary Ellen Klas is a Politics and Policy Columnist for Bloomberg Opinion. A former capital bureau chief for the Miami Herald, she has covered politics and government for more than three decades.