The Affordable Care Act mandated that states allow more low-income Americans and people with disabilities to enroll in Medicaid, a program introduced in 1965 that supplies free or inexpensive healthcare to the needy. Initially, the federal government covers most of the cost, but gradually states assume more of the fiscal responsibility. Medicaid pays notoriously low reimbursements to doctors, patients face long waits to see medical providers that accept the insurance, and since 2003, the Government Accountability Office has designated it as a high-risk program for fraud, abuse, and waste.In 2012, the Supreme Court upheld Obamacare but ruled that states could decide for themselves whether or not to expand Medicaid. In the years that followed, 33 states and the District of Columbia did just that, including Idaho, Utah, and Nebraska last week.“It’s been five years since these decisions have been on the table,” Miller said. “Over time they’re not seeing alternatives for expanding insurance coverage, and the argument is being made, ‘All this money [could be] coming from outside your state. Why not take it?’”A better solution, argued Ryan Streeter, AEI’s director of domestic policies, would be to apply welfare reform principles to Medicaid that help people move out of poverty.Work requirements, health savings accounts, and using federal dollars to pay private insurance premiums are all possible solutions, Streeter wrote. But Congress has lacked the will to legislate those changes. After a dramatic debate over healthcare reform in 2017, the best change Congress could muster was to weaken Obamacare’s individual health insurance mandate as part of a tax reform bill.“Congressional Republicans turned the debate over Medicaid into a technical discussion about per capita funding levels and block grants,” Streeter said. “They never articulated why these reforms would be beneficial for low-income people.”For states, the federal dollars offered to expand Medicaid are becoming too tempting to resist. “Something paid by someone else is better,” Miller said.Medicaid expansion funding will shrink eventually. Currently, the federal government funds just a little more than 90 percent of most states’ programs, and that will continue to drop. But Republicans resistance to Medicaid expansion is dropping faster.