The Affordable Care Act was designed to expand coverage for 30 to 33 million Americans, cutting the number of uninsured non-elderly adults in half. The ACA does this by bringing those deemed “uninsurable” into the market by limiting the ability of insurers to discriminate against Americans with pre-existing conditions or prohibitive costs. The law includes provisions to create private health insurance exchanges in every state. That being said, only 17 states agreed, and the federal government is charged with managing 27 state health insurance exchanges and helping with another seven “partnership” exchanges. This exceptional burden on the federal government has certainly played into the issues with “HealthCare.gov,” the federally-run private health insurance exchange.

Almost half of the increase in coverage comes from the federal expansion of the Medicaid health care program for the disadvantaged. The text of the ACA states that the Medicaid expansion applies to those “who are under 65 years of age, not pregnant, not entitled to, or enrolled for [certain] benefits … and whose income … does not exceed 133 percent of the poverty line.”

Before the ACA, Medicaid programs had complex rules that limited eligibility and left over 45 percent of those living under the poverty line without insurance, and programs in only seven states allowed childless adults to acquire Medicaid. The ACA now expands coverage to all citizens below 133 percent of the poverty line. The Medicaid expansion insures over 15 million Americans (almost half of the newly insured population). The original law mandated that all states accept the expansion or lose all federal Medicaid funding. While the federal government will fund 100 percent of expansion cost between 2014 and 2020— and 90 percent of cost after 2020— court cases have challenged the Medicaid expansion as being coercive. The Supreme Court agreed, placing the decision of whether or not to comply with the Medicaid expansion in the hands of the states.

Twenty-five states decided against expanding Medicaid after the 2012 Supreme Court decision.

By providing states a choice, many Republican governors and state legislatures have justified themselves in deciding not to expand the program. This creates a coverage gap between the median level of Medicaid eligibility before the ACA (47 percent of the federal poverty level [FPL] for parents of dependent children) and the level at which the ACA’s private insurance begins (100 percent of FPL for all adults).

Let us remember the 2012 GOP plan for providing health care to the uninsured. As Mitt Romney said on CBS’s “60 Minutes” during his presidential campaign, “Well, we do provide care for people who don’t have insurance. If someone has a heart attack, they don’t sit in their apartment and die. We pick them up in an ambulance, and take them to the hospital, and give them care.”

The Medicaid expansion was supposed to help control ballooning health care costs, some of which are associated with the fact that some of the 60 million uninsured Americans may get sick over the course of the year. In fact, some of these uninsured Americans may get very sick, they may go to the hospital and they will get care, but if they cannot pay for that care, the costs get passed on to the local system: the hospitals, insurers, doctors and local taxpayers. The Medicaid expansion would have moved these costs to the national system, taking fiscal pressure off the local system.

Republicans dislike the ACA not because it is inherently ruinous for the United States, but because they had no hand in passing it. Democratic presidents and congresses may have formulated Social Security, Medicare and Medicaid, but congressional Republicans had a hand in adjusting, debating and eventually passing these laws. The GOP did not have that chance with the ACA.

In 2009, health care reform was not on the GOP agenda; the last Republican president was an abject failure who left office with low approval ratings; and the Republicans had just lost the White House to the first African-American president in U.S. history. Facing a political reckoning of a younger, less white and more liberal electorate, the GOP ran to the ultra-right, hoping that it could hold the changing electorate at bay. Very conservative Republicans rail against the ACA, but they need to remember 1994, when the Republican proposal for health care reform looked almost identical to the ACA.

The statistics are bleak: an estimated 5,161,820 poor uninsured non-elderly adults fall within the ACA coverage gap because they live in states not moving forward with the Medicaid expansion.  These people constitute 27 percent of all uninsured adults in those states. As a share of low-income (under 139 percent of FPL) uninsured adults in those states, 56 percent fall within the coverage gap, and that share grows even more to 86 percent of poor (under 100 percent of FPL) uninsured adults in those states.

By not expanding Medicaid, 25 states will leave 86 percent of their poor adults uninsured. Republican state governments have ensured that the ACA will fail the poor in their states not because the ACA is flawed, but because the GOP won’t allow it to go into effect.

Zac Bears is a Collegian columnist and can be reached at [email protected].