Document Type

Working Paper

Publication Date





Nearly one in four Americans will have medical care and costs covered by the Medicaid program when it has been expanded pursuant to the Patient Protection and Affordable Care Act (the ACA). National media outlets have been reporting that only about half of the states are participating in the Medicaid expansion; if the reports were true, millions of Americans would be left without insurance coverage, and many of the nation’s medically fragile citizens would not have access to consistent healthcare. Contrary to these reports, most states will participate in the Medicaid expansion in the near future. This claim is not merely predictive; data I have gathered reveals that most of the states currently counted as “not participating” are in fact taking steps toward Medicaid expansion. States’ refusal to expand will create a health insurance black hole for very poor childless adults, 1 but most will not stay in the “not participating” category for long.

This Essay provides preliminary documentation and analysis of states’ evolution toward expanding their Medicaid programs from May through October of 2013, the crucial time period before the key health insurance provisions of the ACA went on-line. The data is still evolving, but if the fluidity displayed during summer of 2013 is predictive, then most states will be participating in the Medicaid expansion in the not too distant future. In addition to the predictive and descriptive counternarrative presented by the data, this Essay illuminates the dramatic, dynamic negotiations occurring between federal and state governments and within state governments. The interest in negotiation undercuts the version of federalism that the Supreme Court protected in the name of state sovereignty in NFIB v. Sebelius. 2 In sum, my preliminary data provides a compelling early story of federalism in action that controverts the common account.

Find on SSRN



To view the content in your browser, please download Adobe Reader or, alternately,
you may Download the file to your hard drive.

NOTE: The latest versions of Adobe Reader do not support viewing PDF files within Firefox on Mac OS and if you are using a modern (Intel) Mac, there is no official plugin for viewing PDF files within the browser window.