As Dylan Scott recently summed it up at TPM, "The GOP's all-out war on Obamacare is in a death spiral." That development should come as no surprise. All along, Republicans opposed the Affordable Care Act not because they believed it would fail, but because they feared it would succeed. And with enrollments exceeding forecasts, health care costs and premiums stable, millions of satisfied newly insured Americans, profitable insurers looking to expand their offerings in the exchanges, and hospitals strong in the states which accepted Obamacare's Medicaid expansion, GOP holdouts including Pennsylvania, Indiana, Wyoming and Tennessee are in the process of extending Medicaid coverage to hundreds of thousands of low-income residents.
Tennessee's may be the most telling--and ironic--case of them all. After all, the failure of its TennCare system highlighted the inability of any one state to provide universal health care on its own. With rural hospitals closing, roughly 300,000 people caught in the "coverage gap" and hundreds certain to needlessly die each year, Tennessee has apparently decided to follow in Arkansas' footsteps and belatedly expand Medicaid.
Facing a reelection battle against Democrat Gordon Ball, long-time Republican Senator Lamar Alexander said the call on Medicaid expansion was Governor Bill Haslam's to make. But in 2009, Alexander had a different opinion. Then, the one-time White House hopeful repeatedly mocked Medicaid as a "medical ghetto." As ThinkProgress documented, Lamar had a not-so-subtle message about which Americans he expected to gain coverage:

- "We've heard eloquent statements about how moving 15 million low-income Americans into a program called Medicaid, which is a medical ghetto, is not health care reform."
- "The governor of Tennessee, who is a Democratic governor, has estimated that the cost to our state of this bill -- of moving 15 million Americans into this medical ghetto -- is about $800 million over five years."
- "Or arrogant in its dumping of 15 million low-income Americans into a medical ghetto called Medicaid that none of us, or any of our families, would ever want to be a part of for our health care."

But that was then and this is now. And now, Tennessee is badly lagging its neighbors Kentucky and Arkansas, where the expansion of Medicaid has led to the sharpest declines in the uninsured rate in the nation. (Tennessee is now considering an approach similar to the Arkansas "private option" in which Medicaid dollars are used to purchase private insurance plans.) Making matters worse, hospitals in Brownsville and other communities face closure because Tennessee Republicans rejected the federally-funded expansion of Medicaid which was designed to replace over time the "disproportionate share hospital" (DSH) payments Washington has been providing to pay for the care on the uninsured. By April, the situation was so dire that Senator Alexander and his Republican colleague Bob Corker begged the Obama administration for $80 million in extra DSH funding to help keep the state's hospitals afloat. As Alexander complained:

"These dollars help Tennessee's hospitals provide care for Tennesseans who need help the most. There's no reason in the world why Tennessee should be the only state without this kind of payment."

Actually, there's no mystery why Tennessee is "the only state without this kind of payment." As Corker's own press release explained:

When TennCare was created through a waiver in 1994, the state agreed to eliminate the Medicaid DSH payment, believing the majority of the uninsured and uninsurable would be covered through the new TennCare. Unfortunately, costs began to escalate quickly and continue to grow, and by 2005, the TennCare coverage experiment ended.

And thanks to the unified opposition of Tennessee Republicans including Corker, Alexander and Governor Haslam, the Volunteer State refused to volunteer for the Medicaid expansion that would have covered up to 300,000 of their constituents and in so doing help prevent the crisis hospitals and clinics there now face. Making the case for one-year hospital bailout from the feds, Lamar Alexander promised:

"I'll continue to work with Senator Corker on a permanent solution."

Of course, the permanent solution is the same now as when President Obama signed the Affordable Care Act on March 23, 2010. Tennessee just needs to expand Medicaid. Then, hundreds of thousands of it residents will enter the ranks of the insured and not, as Lamar Alexander used to cynically warn, a "medical ghetto."