When the Supreme Court decided last spring that it was within the power of states to refuse to expand Medicaid under the Affordable Care Act, plenty of analysts couldn't imagine that many states would actually refuse the free money infusion and opportunity to improve public health. Plenty of analysts underestimated the extremism of Republican governors and legislators. As usual.

With state legislative sessions winding down, and Obamacare implementation gearing up, 20 states and the District of Columbia have decided to take the money, 14 states have refused it, and 16—many with divided government—are still battling out the issue.



The debate has created some unusual battle lines. In Florida, Ohio, Arizona and Michigan, GOP governors wary of turning down billions of federal dollars have met with stalwart opposition from fellow Republicans in the legislatures. The most closely watched of those states is Florida, where an estimated 1.2 million people stand to gain coverage under the provision. With the Florida legislative session slated to end Friday, prospects for the Medicaid expansion appear dim. But in a victory for the Obama administration Thursday, West Virginia Gov. Earl Ray Tomblin (D) announced that his state would participate. His decision is expected to make an additional 91,500 people eligible for Medicaid there. In many states, health-care advocates have allied with business groups and hospitals to endorse expansion. But they have been stymied by conservative groups and the tea party, which are using the Medicaid fight to make a last stand against a health-care law they have battled for more than three years.

The "last stand" isn't necessarily just tilting at windmills, but a concerted effort at sabotaging the law and actively working to make it less effective. Because making it less effective will help in the neverending battle to repeal it. Because winning that political battle is far more important than providing access to health care to people, and they've picked the right political fight. The Medicaid expansion is the most progressive and potentially significant part of the law, providing not just the opportunity to buy insurance but actual access to health care to millions.

On the other hand, decisions made this year on Medicaid expansion aren't set in stone. Though the federal government will only be picking up 100 percent of the tab for the first few years of the expansion, states can decide to take the money at any point. So effective implementation of the program in states that are taking the expansion could help build the case in other states. There's already a strong constituency across the nation for expanded Medicaid: business groups and hospitals, which see the economic benefit of having more people covered with health care that is actually paid for.