U.S

Since the Supreme Court ruling on the Affordable Care Act, states have been grappling with the question of whether to participate in the expansion of Medicaid eligibility. In the aftermath of the 2012 election, how this process will play out is uncertain.

for aging. Highlighting the field's orphan status, a decade-long initiative by the Substance Abuse and Mental Health Services Administration implementing evidencebased geriatric mental health and substance-abuse programs throughout the country was recently eliminated, just as the wave of Baby Boomers turning 65 began to crest. 1 On the research front, National Institutes of Health policy has inexplicably allowed the systematic exclusion of study participants over 65 years of age in federally funded research involving adults (but requires detailed justification for research that excludes women, minority groups, and children). This policy forces clinicians to extrapolate from findings on the safety and effectiveness of treatments that have been tested only in younger adults, and it perpetuates what has been called the "evidence-free" practice of geriatrics.
We believe that steps should be taken to mandate the inclusion of older adults in federally funded research unless there is scientific justification for excluding them, and we agree with the IOM that immediate steps are needed to re-store the national program supporting the implementation of geriatric community mental health and substance-use programs. Emerging Medicare accountable care organizations should integrate geriatric mental health and substance-use expertise as components of health coaching and chronic disease management for patients with complex, high-cost health conditions. The potential for prevention must also be tapped, in part through the adoption of evidence-based psychological interventions that reduce the incidence of depression among patients with health conditions associated with greater risk, such as stroke and macular degeneration. Finally, the fragmentation and neglect of services and research may be addressed by creating a dedicated federal office responsible for overseeing funding and coordination across the different agencies responsible for aging, mental health, and substance-use disorders.
Although these reforms are necessary first steps, they will be insufficient without dramatic changes in what we do and how we do it. If we recognize that mental health care is a core component of general health care for aging Americans and transform the health care workforce accordingly, there may be hope that we can weather the approaching "silver tsunami." Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

W ith President Barack
Obama's reelection in November, the Affordable Care Act (ACA) will remain the law of the land for the foreseeable future. But since the Supreme Court ruling on the ACA, states have been grappling with the option the Court presented -whether to participate in the expansion of Medicaid eligibility to all adults with family incomes at or below 138% of the federal poverty level. In the aftermath of the 2012 election, it is uncertain how this process will play out, but what the states decide will play a critical role in the future of the U.S. health care system.
We undertook an in-depth ex-ploration of the views expressed by governors about the ACA Medicaid expansion from the time of the Supreme Court ruling in June through 1 month after the November election. Although governors are, of course, only part of the state-level policymaking process, they directly oversee each state's Medicaid program in the executive branch and often set the terms of debate with the legislature. We collected public statements (for full methods and references, see the Supplementary Appendix, available with the full text of this article at NEJM.org) 1,2 from documents published in the summer and fall of 2012. In five states with newly elected governors, we included campaign statements from the winning candidate. We identified major themes voiced by governors and cross-tabulated them according to whether each governor supports the expansion, opposes it, or remains undecided (see Table 1). We then identified any changes since the election.   Table 2 shows the most common themes, according to governors' support for or opposition to the Medicaid expansion. Among governors opposed to expanding Medicaid, statements about affordability and impact on state budgets were nearly universal (92%). Cost concerns fell into several categories. Some pointed to the so-called woodwork effect, in which the ACA could draw previously eligible but unenrolled persons into Medicaid, at greater cost to the state. More than half the governors opposing expansion predicted that the federal government would renege on the generous terms of the ACA and scale back its share of Medicaid spending. Newly elected Governor Mike Pence (R-IN) compared the expansion to "the classic gift of a baby elephant. . . . The federal government says, 'We'll pay for all the hay -for the first few years.'" Beyond cost, governors expressed concern about the lack of state flexibility or their belief that Medicaid may foster dependence among beneficiaries. For instance, Dennis Daugaard (R-SD) declared that "able-bodied adults should be self-reliant" -in contrast to children or people with disabilities, the traditional Medicaid beneficiaries. Others argued that Medicaid itself is the problem, calling it a "broken program" that provides poor care. Most vividly, Rick Perry (R-TX) said that adding uninsured Texans to Medicaid is "not unlike adding a thousand people to the Titanic." Governors supporting the expansion focused on the desire to expand coverage to uninsured persons, arguing that insurance would lead to greater access to care and improved health. Jay Nixon (D-MO) explained, "This will improve the health and the quality of life for hundreds of thousands of Missourians." Many governors who support the Medicaid expansion argued that it builds on previous coverage expansions in their states and that it would actually save their states money by replacing local dollars with federal funds. Peter Shumlin (D-VT) explained that opponents "are acting like we are not already paying for this. What we're proposing . . . is to pay less for something that we are already paying for right now." Among uncommitted governors, there were three dominant themes. First, three quarters of these governors said they needed more information on federal requirements, cost and enrollment projections, and policy alternatives. Second, affordability was a key concern, including the possibility of decreased federal funding in the future; as Jan U.S. GovernorS and The Medicaid expanSion  Brewer (R-AZ) explained, "At any whim they could just pull the money. So yeah, I'm a little gunshy." Finally, early on, nearly one third of undecided governors said they were waiting until the election to evaluate their options.
Although some may have expected the uncertainty to resolve swiftly after the election, that has not happened: as of January 2013, a total of 15 of the 26 governors who were undecided before the election remained undecided (see Table 1). Some of this uncertainty reflects ongoing efforts to gather information about what will be permissible under the law. Several governors petitioned Medicaid to permit partial expansions, such as including only people with incomes of up to 100% of the federal poverty level. They reasoned that the federal government would pay the full cost of tax credits for people with incomes between 100 and 138% of the poverty level who sought health insurance through an exchange, whereas under the Medicaid expansion, states will have to pay 10% of the costs in the long run. However, the Department of Health and Human Services recently clarified that partial expansions would not be permitted. 3 Some ACA supporters contended that governors' opposition after the Supreme Court ruling was simply preelection political posturing and that most states would find the ACA's generous federal funding impossible to refuse. 4 Some of the movement since the election bolsters this perspective: six governors have newly announced their support, including the first two Republican governors to publicly en-dorse the expansion. Two other governors who previously opposed the expansion have now indicated that their minds are not completely made up. Rick Scott (R-FL), previously one of the most vocal opponents of the law, explained, "The election is over, and President Obama won. I'm responsible for the families of Florida. . . . If I can get to yes, I want to get to yes." However, not everyone changing position has endorsed expanding Medicaid. Five previously undecided Republican governors are now opposed, and some governors say they won't decide until 2015 or 2016. Some opposition may remain a negotiating ploy by governors with respect to opposing lawmakers or the federal government, but predictions of a rapid, pro-expansion resolution were apparently mistaken. Moreover, governors are only part of the story; several statehouses (including the Republican-led Missouri legislature and the newly Democratic Maine legislature) plan to oppose their governors' positions on the expansion.
Overall, these results demonstrate governors' conflicting views about the value of expanding insurance coverage versus the costs and federal oversight involved in doing so through Medicaid. As the dust has settled after the elections, no clear consensus has emerged, with 17 states still undecided and well under half supporting Medicaid expansion. It now appears that the ACA's 2014 coverage expansion will have large unintended gaps, as low-income adults in at least a dozen states remain ineligible for any kind of public subsidy for health insurance. Although those with incomes above 100% of the federal poverty level will be eligible for tax credits for exchange coverage in states that decline to expand Medicaid, that will still leave millions of adults living below the poverty level without health insurance and without the means of acquiring it.
Though Medicaid was initially enacted in 1965, nine states did not participate until 1970 or later, and it took nearly 20 years before the last holdout joined. 5 One can only speculate about whether that history is about to be repeated, with insurance coverage for millions and the fate of the ACA hanging in the balance.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.