Q: What are some of the arguments against the Medicaid expansion?
A: A federal government awash in debt can't be trusted to keep its promises. States that expand coverage will be hard pressed if Washington later tries to scale back its financial commitment. It won't be easy to simply pull the plug on the expansion because people will be depending on the coverage. States could get hit with a cost shift.
Washington passed up the opportunity to overhaul Medicaid's convoluted rules and give states more flexibility with the program. Medicaid is a major share of the budget in every state, forcing wrenching decisions between health care and other state priorities such as education and law enforcement. Even if states pay only a fraction of the cost, that is still real money.
Q: Any other concerns for states?
It's estimated that even before Obama's health care law, millions of people were eligible for Medicaid but were not signed up.
With the new requirement in 2014 that virtually all Americans have health insurance, states fear these low-income people will come out of the woodwork and enroll to comply with the mandate.
The Urban Institute estimates 7 million will sign up, mainly children.
It will be an issue in every state, even the ones that reject Obama's Medicaid expansion.
The cost of covering what state officials are calling the "woodwork population" will be divided up under standard federal matching rates, not the more generous one provided in the health care law.
Q: How is this debate likely to shake out?
A: So far mainly Democratic-led states are signing up for the expansion. But some states with Republican governors have also accepted it, and others red states are actively considering it. All the states declining the option are led by Republicans.
If the past is any guide, some states will not sign up for the expansion by 2014. But over time, experts say it's likely that all states will accept it.