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The battle for Medicaid expansion is getting messy

Joe Raedle/Getty Images

President Obama's decision to rename Denali got more attention, but this will affect more lives: Alaska on Tuesday officially expanded Medicaid through the Affordable Care Act, the 29th state to do so. An estimated 40,000 Alaskans are now eligible for coverage.

"Many Alaskans are working two or three jobs to make ends meet, and have not been able to afford health insurance," said Gov. Bill Walker — a Republican turned independent. "The Healthy Alaska Plan ensures that working Alaskans will no longer have to choose between health care and bankruptcy."

It didn't get much attention in the lower 48, but I'd been watching Alaska's months-long debate over the Medicaid program. And Tuesday's expansion very nearly didn't happen: Walker and the state legislature had been locked in a flurry of lawsuits and motions that went all the way up through Monday, before the Alaska Supreme Court permitted the expansion to proceed. (Meanwhile, the lawsuit against Walker is still underway.)

This isn't how Obamacare observers expected the fight over Medicaid expansion to play out.

After the 2014 midterm elections, and again after the Supreme Court ruling on the ACA this summer, some predicted that a wave of holdout states would start accepting Medicaid expansion — partly to take advantage of federal funds, and partly as the Affordable Care Act became less of a hot-button issue.

Instead, Alaska could end up as a road map, as these knock-down, drag-out battles over Medicaid expansion might be the new normal for the foreseeable future.

Medicaid expansion map

(Dan Diamond/Vox)

One major factor is that the GOP won historic statehouse victories last fall — and these rank-and-file Republican legislators remain skeptical of the ACA and its Medicaid expansion.

And party leaders are still wary of the implications, given that prominent Republicans aren't being rewarded for their pro-Medicaid decisions. Take Govs. John Kasich and Chris Christie, who both expanded Medicaid in their respective states. Now as presidential contenders, neither has gotten any traction in the polls, and Kasich was pushed to defend his decision at the first Republican debate.

(Then again, Louisiana Gov. Bobby Jindal has been one of the fiercest critics of the Medicaid expansion, and he's still stuck in the second tier of presidential candidates.)

Some resistance is clearly political; one Georgia legislator drew up a bill last year that would've made it illegal for state employees to even say "Obamacare" except as a curse, Jim Galloway points out for the Atlanta Journal-Constitution.

But Republican leaders say there are real, logistical reasons why they're holding out against Medicaid expansion. The biggest one is cost: Florida is already spending nearly $25 billion on Medicaid this year, and enrollment continues to grow even though the state didn't expand the program through the ACA.

There are some signs of movement, partially because the Department of Health and Human Services is beginning to pressure states to expand, warning that they could lose billions in federal funds for uncompensated care if not.

Edgar Walters reports for the Texas Tribune that Gov. Greg Abbott has been exploring Medicaid expansion, for instance. As many as 2 million Texans would be eligible for Medicaid coverage, if the state deigns to accept the ACA expansion.

Don't expect any near-term breakthroughs on Medicaid negotiations, though. With most statehouses now out of session, a kind of eerie stasis has settled over the expansion debate.

But almost 2,000 days since the Affordable Care Act was signed into law — and more than 1,100 days since the Supreme Court gave states the right to choose — the fight over Obamacare continues. And this last battle isn't going to end anytime soon.

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