Gee said health-care challenges in Louisiana go beyond enrolling more people, whose coverage costs the federal government will pay this year. She described those problems with urgency in her voice: one northern city with a facility whose infant-mortality rate is “double many developing countries”; a statewide high HIV rate; high syphilis and STI rates; infants with neonatal abstinence syndrome, also known as neonatal withdrawal; and drug use. She paints a picture of Louisiana as a state rich with cultural tradition, but cripplingly poor, and she’s putting out a “call to arms” for “nontraditional partners and stakeholders,” like foundations, to help combat the state’s health-care troubles.

Louisiana’s needs, when taken together, help illuminate why Edwards’s Republican opponent in the election, U.S. Senator David Vitter, wouldn’t rule out supporting an expansion—with conditions—in their knock-down, drag-out contest. (And as one Medicaid supporter notes, it may’ve helped that polls of Louisianans showed a “simple majority” of those surveyed favored it, too—and that Louisiana’s deficit is linked to the state’s steep Medicaid payments.) That’s not to say that Vitter was following in the footsteps of the Republican he hoped to succeed, two-term executive Bobby Jindal, who opposed it to the bitter end. He frequently cited the costs to the state and his opposition to government-run health care to explain his resistance. Even after Edwards’s election, Jindal wouldn’t concede that expansion was in the works. He pushed back on calls from legislators to help prepare the health department for expansion ahead of Edwards’ inauguration.

It’s not yet known how the Republican-dominated legislature will respond to Edwards’ executive order. The Baton Rouge Advocate reported last month that Republican lawmakers are showing “more willingness” to cooperate with expansion, though they’ve historically opposed it. They’re not the only detractors expansion has seen. Dawn Starns, Louisiana state director for the National Federation of Independent Business, said business owners question why the state is choosing to expand Medicaid at a time when it’s facing huge budget deficits. “For us, this is a conversation about state budgeting and money, this is not a conversation about access to health care or … whether people deserve it or not,” Starns said.

Gee emphasized that Louisiana needs to come up with creative ways to find funds for health care, and not only when it comes to Medicaid. According to a new administration assessment, the state is working with a $750 million deficit through the end of the current fiscal year, and a $1.9 billion deficit for the next, which begins July 1.

Louisiana health department officials have gone as far as to ask hospitals, clinics and other entities for donations to cover the state’s portion of this year’s administrative costs for expansion, roughly $2.8 million, including salaries for 248 new enrollment workers. (The federal government, too, will kick in funds for these costs in 2016 and beyond.) The state is also asking hospitals and other facilities to donate office space for those state employees. Starns said health-care providers’ donations to cover costs are “great” in the short term, but that business owners are concerned about state spending over the long haul.