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The Patient Protection and Affordable Care Act (ACA) was an unprecedented gamble. The ACA transformed Medicaid from an unevenly and underfunded program for the poor and disabled to a program to offer those priced out of commercial insurance markets government-funded health insurance similar to Medicare, the single-payer system for seniors and the disabled. In a sense, the ACA gambled that Medicaid could be more like Medicare.

The ACA, as it was transformed by the Supreme Court of the United States, became a gamble on the part of the Court that good things would follow from empowering each of the states to individually determine the fate of Medicaid expansion in its jurisdiction. Giving states the option to expand has given each of them enormous leverage in their bargaining with the federal executive and legislature over what shape their individual version of this jointly-funded state-federal program will take.

The ACA’s Medicaid expansion or non-expansion on the ground, as it is being carried out by the states cooperatively or uncooperatively with the federal government, is likely to be a third thing. The country is likely to see all possibilities happen at once, in different places. In some states, Medicaid is likely to become much more like Medicare. In others, Medicaid may change slowly and incrementally, if at all. And, in others, Medicaid may become more like exchange-mediated commercial insurance.

This article will address what these Medicaid gambles are, how these gambles are likely to resolve themselves, and whether Medicaid as we know it is likely to survive the ACA.

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Journal of Health Care Law & Policy