The Supreme Court’s historic June 2012 ruling regarding the Affordable Care Act (ACA) in National Federation of Independent Business v. Sebelius set the stage for a massive federalism battle over Medicaid expansion in the United States. The original language of the Act was intended to nationalize Medicaid by having every state expand their program’s eligibility to all individuals up to 138% of the federal poverty level. This would have significantly reshaped Medicaid, a joint federal-state health insurance program, into a universal entitlement for all low-income citizens. Currently, Medicaid eligibility varies dramatically from state to state. The Court held that the ACA’s Medicaid expansion, and the additional federal financing that would accompany it, would be optional for the states. The decision instigated a series of intense, state-level political battles, especially in Virginia. This article will provide a basic overview of: Medicaid and its significance in Virginia, how and why the Supreme Court’s decision triggered a heated debate over Medicaid expansion, the manner in which the political debate has unfolded in the Commonwealth, and what the major implications are for expanding (and not expanding) the program. This article concludes that Medicaid expansion can be viewed as a valuable investment in the health of vulnerable citizens and the overall healthcare infrastructure of Virginia.

Document Type


Publication Date

Fall 2014

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Copyright © 2014, University of Richmond. This article first appeared in Richmond Journal of Law and the Public Interest: 18:1 (2014), 23-37.

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