Gov. Jan Brewer on Monday signed the largest expansion of Arizona’s Medicaid program since its inception a generation ago, ending a fierce five-month legislative battle that drove a wedge through the Republican Party.

A state consultant says most of the 58,000 people who would qualify for Medicaid under the expansion would either remain insured under private coverage or be able to buy subsidized insurance through a health exchange established by the federal law if the program isn't expanded.

Gov. Rick Snyder signed a 2013-14 state budget that doesn't address two of his major priorities - expanded Medicaid coverage and raising more than $1 billion in extra revenues for repair and maintenance of state roads and bridges.

Gov. Jan Brewer's proposal was met with derision from conservatives who argued that it was a massive expansion of government, would drive the federal government deeper into debt and that the government promises of paying for the expansion would turn out to be false.

The House is poised to approve a $28.3 billion spending plan for 2013-14. It would increase funding for basic education by $100 million, provide money to hire 300 state troopers and boost overall spending by 2.1 percent.

In the wake of a 2012 Supreme Court ruling, states face complex decisions con cerning whether to expand Medicaid coverage as specified in the Affordable Care Act (ACA). With the federal government no longer able to coerce expansion, states must base their decisions on subjective value judgments that will vary from state to state, incorporating each state's unique budgetary circumstances, the needs of its uninsured population, and the incentives established by interactions between the ACA's provisions. A first important consideration is that states face substantial near-term Medicaid cost increases irrespective of coverage expansion decisions.

Alternative views on the problem the United States is facing: financing retirement consumption as its population ages.

The Patient Protection and Affordable Care Act (PPACA), signed into law on March 23, 2010, made significant changes to the way eligibility for the Medicaid program will be determined and who the program will cover. State governments will play a key role in implementing many aspects of this reform, which must be in place by the beginning of 2014. States will need to address the financial implications of implementing this Medicaid expansion and accompanying enrollment systems.

State finances are not transparent and often include hidden liabilities as well as rapidly growing responsibilities which are difficult to control.  While state revenues are gradually recovering from the drastic decline of the Great Recession, they are not growing sufficiently to keep pace with the spending required by Medicaid costs, pensions, and other responsibilities and obligations.  This has resulted in persistent and growing structural deficits in many states which threaten their fiscal sustainability.

An examination of Medicaid spending by state over a decade.  In 2009, the 10 states where per capita spending was highest ranged from 13 to 36 percent higher than the national average, and the 10 states where per capita spending was lowest ranged from 8 to 26 percent below the national average.

Three Things to Fix Health Care Now:

#1: Reject the Health Insurance Exchange
#2: Don't Expand Medicaid
#3: Offer an Alternative

Supporters of Obamacare claim that expanding Medicaid will entail little to no cost to state governments, since the federal government will fund the vast majority of the additional costs. Indeed, some analyses project states achieving savings from adopting the expansion. However, state lawmakers should be wary of accepting such analyses at face value.

Block-granting Medicaid is the best way to deliver better, cost-effective care to the most vulnerable Americans.

Any serious attempt at state budget reform in North Carolina must include an examination of its Medicaid program. Costs have been soaring, and past cost-containment efforts have proven both insufficient and detrimental to enrollees' access to care. Moreover, Medicaid enrollees are merely passive participants in the program with little or no choices, and at the mercy of the whims of politicians.

The Health Care Compact is an interstate compact - which is really just "an agreement between two or more states that is consented to by Congress" - that would return the authority and the responsibility to regulate health care back to the member states.