State Medicaid policy and health reform.

In July 2012, the Supreme Court upheld the constitutionality of the Patient Protection and Affordable Care Act (PPACA). The Court thus ended one phase in the political and legal battle over health reform. Yet in doing so, it opened a new front. In a notable departure from post– New Deal commerce clause jurisprudence, the Court ruled that the federal government could not require states that receive federal funds under the Medicaid program to participate in the PPACA’s Medicaid expansion. In effect, the Court made states’ participation in the PPACA’s Medicaid expansion voluntary — a possibility that neither the act’s supporters nor its opponents seriously entertained during the long legislative battle of 2009 and 2010. The full implications of these changes in federalstate relations remain to be seen. For states, the ruling brings both new flexibility and new accountability. Conservative legislators who have traditionally railed against Medicaid while accepting large subsidies will now have to actively accept or reject billions of dollars in federal resources made possible through this program. For the federal government, the ruling brings new uncertainties and complication, as states decide whether and when to participate in the PPACA’s Medicaid expansion. For millions of citizens, this decision likely delays the path to nearuniversal coverage envisioned under the new law. This issue’s PointCounterpoint essays underscore the difference in perspective among informed participants regarding what may be the most complex and contested measure in the history of American social policy.