[S]tates face a relatively simple (albeit stark) choice when it comes to Medicaid. They can either accept the new Medicaid spending required under the ACA or they can reject the "deal" offered by Congress, in which case they must forego all federal funding of Medicaid.States are caught between a rock and a hard place as state spending (and budgets) explode out of control. Conover concludes:
The problem with salami tactics like those encouraged through federal matching programs such as Medicaid is that eventually we will run out of salami. It's very generous for the federal government to offer 90 percent matching in perpetuity for those newly eligible under the ACA. But it is not at all clear Uncle Sam is in a position to fund this promise, especially in light of the fiscal tsunami posed by Medicare in the decades ahead.If you live by federal money, you die by federal money.