The Affordable Care Act and the Politics of the Medicaid Expansion

The Patient Protection and Affordable Care Act (ACA) seeks near-universal health insurance coverage in the USA. Medicaid is central to this expansion: half of the newly enrolled population was initially scheduled to participate in the program by extending eligibility to all households with income at or below 138 percent of the Federal Poverty Level. However, in 2012 the Supreme Court ruled that states had a choice of whether to adopt the expansion. Currently, 23 states have opted out, undermining the ACA significantly. This article assesses how partisanship, in the overall context of the neoliberal agenda, has affected US state governments in making the decision as to whether they will participate in this key component of President Obama's reform bill. It contends that Democrats and Republicans have separate but interrelated visions for the neoliberal state. The article also discusses how a number of reluctant states are attempting to take advantage of federal expansion money by proposing market-based alternatives. Finally, it addresses the various vested interests affected by the Medicaid expansion decision.