Assuming Barack Obama is re-elected in 2012 and the Affordable Care Act is implemented starting in 2014, which states are most likely to decline the federal government's offer to expand Medicaid on extremely generous terms?
In the very short term, the decision is likely to be based on idiosyncratic elements of local politics. Gov. Rick Perry of Texas has defined his political career in terms of sharp antagonism to the federal government, and Gov. Rick Scott of Florida has defined his political career in terms of sharp antagonism to the Affordable Care Act. But it's by no means clear that either of those men will be in office in 2015. Over the longer term, Medicaid expansion should be driven by structural factors rather than the peculiarities of any particular politician.
The way I see it playing out, in most places local health care providers—hospitals, doctors—plus the national pharmaceutical industry will exist as a powerful lobby in favor of expansion. More Medicaid equals more customers. Certain classes of low-wage employers should also favor expansion. That means the greatest opposition to expansion over the long term may come not from places like Texas but from the low-population states of the Plains. Why? Because those are the places most likely to be suffering from shortages of doctors and other health providers. In a place where people worry about provider shortages, Medicaid expansion won't do existing providers much good. And the existing set of insured people will worry that completely aside from financial issues, Medicaid expansion will mean fewer doctors' appointments and hospital beds to go around.