“For states, it’s the medium to long-term fiscal picture that presents the biggest worry. The long-term politics of federal budgeting make short-term state policy choices rather dicey: Who knows what Congress will do as the cost of government health programs rise and the already bad budget situation grows worse? Cost shifting to states may not be inevitable, but it’s quite likely, which means that even if expanding Medicaid is essentially free now, it almost certainly won’t be in the future.”