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Advocate staff photo by BILL FEIG -- From left DHH Secretary Dr. Rebekah Gee DHH Medicaid Expansion Project Director Ruth Kennedy and Gov. John Bel Edwards stand for a photo after a Medicaid expansion announcement event.

Against all odds, Louisiana has become the 31st state — perhaps more noteworthy, the first state in the Deep South — to expand Medicaid through the federal Affordable Care Act, granting thousands of people no-cost health insurance more than six years after “Obamacare” became the law of the land.

Louisiana’s improbable journey to Medicaid expansion, which officials say will help an estimated 375,000 people gain access to health care coverage in the coming year, has had several twists and turns, behind-the-scenes dealings and highly publicized promotional events, as well as public pleas and assists from unlikely sources.

“I believe there is nothing we could have done that would be more impactful on the future of this state,” Department of Health Secretary Dr. Rebekah Gee said confidently.

Just a year ago, Medicaid expansion was something of a nonstarter for Louisiana. Its prospects remained hazy at best.

Gov. John Bel Edwards, a Democrat who took office in January, had tried for years as a state legislator to get Louisiana to embrace the idea. But then-Gov. Bobby Jindal, a Republican with a special interest in health care and an eye on the White House, wouldn’t allow it.

Edwards campaigned heavily on the idea of expanding Medicaid to give health care coverage to thousands of the working poor in Louisiana, bringing “our federal tax dollars back home” rather than using them to subsidize other states that have embraced expansion.

“It’s not right versus left,” Edwards said recently. “It’s right versus wrong.”

Perhaps ironically, much of the framework for expanding Medicaid, at least initially, has relied on policies and programs put into effect under Jindal.

“I don’t know that Louisiana ever had universal opposition to expansion,” state Medicaid director Jen Steele said.

Some 580,000 Louisiana residents are estimated to be eligible for Medicaid under the newly expanded income-level requirements.

The Louisiana Department of Health’s goal is to enroll at least 375,000 of them in the coming year.

One of the biggest issues for the state as it weighed expansion: Louisiana was barreling toward an estimated $2 billion funding shortfall in the budget that began July 1. Expansion offered a way to infuse federal dollars into the state’s Department of Health, money that state leaders say will save $184 million in the coming year.

“The public is largely supportive of Medicaid expansion,” Gee said. “I think the budget crisis was certainly a catalyst for the Legislature to come on board.

“Expansion is coming at the perfect time,” she added.

It’s not that there aren’t detractors.

State Treasurer John Kennedy, a Republican running for the U.S. Senate this year, has launched a media blitz to highlight what he has deemed rampant Medicaid fraud — in the process drawing attention to both his campaign for higher office as well as efforts he says can save the cash-strapped state some money.

During the regular legislative session that ended June 6, nearly a dozen bills or resolutions were considered that threatened to take some of the expansion power away from the administration, though none made it far through the process.

Generally speaking, though, the administration admits that it initially braced for more of a fight.

“It certainly could have gone another way,” Gee said.

Facing an aggressive push from Edwards’ administration to have expansion up and running by July 1, the state Department of Health initially wanted to hire 250 people to help with enrollment.

“That would have been the easy way to go — the more tried-and-true way to go,” Gee said.

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But the potential pushback from legislators and the public as the state faced a potentially catastrophic budget shortfall forced the Edwards administration to back off from a request to hire more people.

There was even more behind-the-scenes maneuvering.

Health Department spokesman Bob Johannessen said a plan was carefully implemented and weekly meetings were held to address concerns about pushback. At that time, it was decided that the message would focus on broad bipartisan talking points such as job creation, budget savings and economic impact.

“We spent a lot of time with legislators who we had an indication might oppose expansion,” Gee said.

That included meetings with detailed maps showing how each lawmaker’s district specifically would benefit — from the number of constituents who would be eligible to the jobs created.

“I think that was an important part of the process,” Gee said.

The other piece of the puzzle: figuring out how to sign up people with no extra funding. “We didn’t know how we were going to make this happen,” Gee said.

The first big push came from an unlikely source. Thousands of people have been automatically added to the Medicaid rolls thanks to programs created under Jindal, the hard-line Republican governor who unwaveringly opposed Medicaid expansion during his eight years in office.

Jindal, who unsuccessfully ran for the Republican presidential nomination last year, had developed his own alternative to the federal Affordable Care Act, often affectionately called the “Jindalcare” alternative to “Obamacare.”

Ruth Kennedy, who has spent nearly two decades in the Louisiana Department of Health under both Democratic and Republican administrations, has served as the largely behind-the-scenes architect of Louisiana’s Medicaid expansion. “I’m all Medicaid expansion all the time,” she said.

Kennedy said health officials knew expansion would happen “at some point” and have bided their time, planning and waiting for the day.

Kennedy said the Take Charge Plus program begun under Jindal was viewed as a bridge to expansion, and health officials would regularly hear from people who lamented that it didn’t offer more services.

“We would say, ‘Just hold onto it. We may add additional services,’ ” Kennedy said. “It’s a very limited benefit. It’s a false narrative to say those people have health care coverage.”

Take Charge Plus was an opt-in program that focused on family planning and the screening and treatment of sexually transmitted diseases. Its implementation actually came at the recommendation of the often-maligned Alvarez and Marsal consulting firm that has drawn the ire of Jindal’s critics.

Nevertheless, it’s paid off for those who support Medicaid expansion.

“It was absolutely our bridge,” Ruth Kennedy said.

While no Southern state has reached out to Louisiana directly, both Gee and Edwards say they are confident that Louisiana is being watched — viewed as a potential model for making Medicaid expansion work in one of the poorest and sickest states in the country.

“Of course they are watching us,” Gee said.

Edwards goes a bit further.

“I predict to you that by this time next year, there will be four or five more” states doing the same thing, he said, if Democrat Hillary Clinton is elected president.

Warner Thomas, president and CEO of Ochsner Health System, said the goal is to build partnerships with community health centers to try to build a network of care that the state hasn’t seen before.

“The expansion, we think, is a good thing for Louisiana. It’s a good thing for the communities and the folks in our communities,” he said. “Hopefully, we will have very few people uninsured in Louisiana, thanks to Medicaid expansion.”

Follow Kyle Whitfield on Twitter, @kyle_whitfield.​