Red-State Health Reform:
Threading the Political Needle
Robert B Leflar*
The Supreme Court’s decision in National Federation of Independent
Business v. Sebelius1 gave each state the option to accept or reject federal
funds for the expansion of Medicaid health care coverage.2 The decision
sparked political battles across the nation. Republican resistance to
acquiescence in any aspect of “Obamacare,” coupled with continued public
skepticism about the overall merits of the Affordable Care Act,3 has
blocked implementation of the Medicaid expansion in almost half the states
(chiefly southern, plains, and mountain states) as of this writing.4 About an
equal number have expanded their traditional Medicaid programs.5
However, six states have adopted – with considerable Republican support –
nontraditional federally funded alternatives (Fig. 1).
*Ben J. Altheimer Professor of Legal Advocacy, University of Arkansas School of Law,
Fayetteville, Ark.; Professor, University of Arkansas for Medical Sciences, Little Rock;
email@example.com. I thank Frank Griffin, Elizabeth Weeks Leonard, Kevin Ryan, Sidney
Watson, and Craig Wilson for their useful suggestions.
1. Nat’l Fed’n of Indep. Bus. v. Sebelius, 132 S.Ct. 2566 (2012).
2. See id. at 2601-08 (opinion of Roberts, C.J., joined by Breyer and Kagan, JJ., stating
that the Affordable Care Act requirement that states expand their Medicaid programs or
suffer cutoff of all federal Medicaid benefits “coerced” the states in contravention of
federalism principles); see also id. at 2661-67 (Scalia, Kennedy, Thomas and Alito, JJ.,
dissenting) (agreeing with Roberts, C.J. and Breyer and Kagan, JJ. that the A. C. A.
requirement that states expand their Medicaid programs was unconstitutional).
3. What I refer to as the “Affordable Care Act” is actually two enactments: the Patient
Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), and the
health care-related portions of the Health Care Education and Reconciliation Act of 2010,
Pub. L. No. 111-152, 124 Stat. 1029 (2010).
4. See infra Figure 1.