As a practical matter, I think accepting 100% federal funding to extend Medicaid coverage to adults and getting that coverage up and running is easier than setting up a state-based marketplace, implementing the new insurance reforms and tax credits etc etc. States obviously already have Medicaid programs up and running – in many cases with managed care companies providing the service and eager for more business.

As it stands now, millions of low-income uninsured Americans will not qualify for Medicaid in 2014 due the failure of about half of all states to accept the federal dollars for the Medicaid option.  I am optimistic that we are going to get there though eventually, and it seems to me that we are now entering the second phase of Medicaid expansion – those (mostly) Republican Governors who do want to accept the federal dollars, but who for political reasons don’t want to look like they are expanding Medicaid.

So new variants are being developed – Arkansas — which I have blogged about repeatedly – Iowa, Michigan, and now Pennsylvania – which combines all of the above and adds a new twist — job search requirements.

It looks like CMS will be as flexible as they can possibly be without crossing certain lines that the law will not let them cross – and which they likely don’t want to cross anyway.  If the Governor of any of these states is serious about accepting the federal dollars and extending coverage, there is a deal here to be had. If not, then I will conclude that scoring political points is the primary motivation of this recent spate of announcements.

So where these negotiations end up will bear watching. But one thing is for sure — Medicaid waivers are proliferating, and with them enormous growth in the administrative complexity of the ways in which Medicaid will be operated. All of the state waivers mentioned above will result in extraordinarily complicated eligibility and enrollment practices – which is an unfortunate byproduct of where the debate has gone. Not an outcome perhaps that Chief Justice Roberts anticipated. But ultimately, perhaps, a price worth paying to ensure coverage for millions of Americans.