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Journal Article


Challenges Facing Medicaid Expansion in the U.S.

The Issue

As part of its goal to cover the uninsured, the Affordable Care Act established a major expansion of the Medicaid program. This provision, however, was deemed optional for states by the Supreme Court in 2012. The authors of this study, all 2012–13 Commonwealth Fund Harkness Fellows, provide an international perspective on the challenges facing the Medicaid expansion.

What the Study Found

By focusing on Medicaid—a joint state–federal program—the Affordable Care Act reignites a fundamental tension in the United States between federal and state decision-making. The issue is not unique to the U.S., say the authors. In Australia, for example, the federal government funds benefits for outpatient services and pharmaceuticals while the state provides funds and services for public and psychiatric hospitals and public health. This creates tension and cost-shifting between the states and federal government.

In Switzerland, responsibility for health care is shared between the state, cantons, and municipalities, making the system difficult to steer. In the U.S., internal politics within states will also play a key role, as states that choose not to expand Medicaid will lose out on federal dollars and feel pressure from hospital lobbyists.


The major health care reforms of Europe, Canada, Australia, and New Zealand have resulted in substantial benefits for these countries’ populations. While implementation of the Affordable Care Act seems daunting, the Medicaid expansion, together with the law’s other coverage expansion provisions, have the potential to be similarly beneficial in the United States.

Publication Details



D. Noble, N. Biller-Andorno, J. M. Sutherland et al., "Challenges Facing Medicaid Expansion in the U.S.," BMJ, published online May 29, 2013.