Its not handwaving. Your just asking for things way outside of what the data shows. Yeah could be implementation as there are better and worse ways to do it, but it could also be what the rest of the states healthcare system is like. North carolina im not so sure is super red. Maybe my map knowledge is off but nevada looks a bit regional. Its possible gambling and general debt could be effecting it. It could be all sorts of things. This picturejust shows that in general expanding medicaid seems to correlate with less medical debt.