Expanding Medicaid under the ACA can have potentially permanent consequences for states and their residents. Policymakers should resist the temptation to go along on the attenuated hope that Washington will allow them latitude in designing long-term cost-saving and delivery measures. Seeking special dispensations from federal agencies every few years is no way to achieve sustainable reform.

Section 1115 waivers were effective tools for states to use in their policy laboratories in the past as states experimented with expanding eligibility into optional populations and reforming the service delivery system. But what were optional populations in the past become mandatory populations in expansion, which carry the full mantle of entitlement. The record of the past five years demonstrates greater federal control over the Medicaid program in every area (including the very process for obtaining a waiver). It is simply wishful thinking that the current administration will suddenly reverse course entirely and weaken the entitlement status.

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Any waiver obtained is likely to be far too limited — given HHS imposed restrictions which foreclose work and other personal responsibility  requirements — and far too precarious — given the short duration and need for discretionary re-approval — to offer states a viable long-term solution. Any decision to accept the Medicaid expansion today should not be based on the illusory promise of a federal waiver tomorrow.