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.

As the state Senate finished voting Saturday on a bill to extend a tax on managed care plans, Senate President Pro Tem Darrell Steinberg told reporters at the back of the room, "That is what's called a supermajority."

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 size of unfunded retiree healthcare liabilities varies widely by state. While some states have been making slow progress towards pre-funding these obligations, other have been contributing to them on a pay-as-you-go basis. As a result of the latter approach, combined unfunded liabilities are $425 billion under the most optimistic assumptions.

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.

The Republican-led Legislature adjourned in April without passing a Medicaid budget because members couldn't agree on expansion. And if they don't come up with a solution, the program goes out of existence on July 1.

The Kasich administration is in the position of dickering with lawmakers over what shape the program could take while dickering with the federal government on what it would find acceptable.

While it's not unusual for the Legislature to delay some decisions and amend the budget later, the unresolved issues on roads and Medicaid are so enormous - amounting to $2.5 billion in new spending - that it can be considered a stretch to say the budget is finished.

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.

Was the slow recovery of the U.S. economy from the trough of the Great Recession anticipated? 

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.

A map and chart ranking Medicaid spending for each of the 50 states in FY2010.

In the long term, the decline in the sector's operating balance is primarily driven by the rising health-related costs of state and local expenditures on Medicaid and the cost of health care compensation for state and local government employees and retirees.

Among the 50 state employee health benefit plans, there is considerable variation in premium rates and in how the costs are shared between the state and employee.The average premium for a standard family policy was $1,377.03, with the state paying an average of $1,096.63 (80 percent) and the employee paying the remainder. (Based on 42 states.) The average premium rate for the lowest cost family insurance option was $1,101.28, with the state paying an average of $974.66 (88 percent).

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.

The sixth-annual Tennessee Pork Report is chock-full yet again, of waste, fraud, abuse, and mismanagement of taxpayer money by state and local government officials. Despite a changing political landscape in Tennessee, wasteful government spending has not disappeared.

Replacing MinnesotaCare with a state subsidy for individually owned private health plans is one of the key parts of the effort to redesign how the state provides health care to the poor. This can save $100 million on childless adults and up to $600 million if everyone is included.

In light of Oregon facing a budget crisis, the Taxpayer Foundation has issued a master list of budget balancing ideas that do not require raising taxes. These ideas have been collected from Oregon lawmakers, think tank groups, taxpayer organizations, unions, policy analysts, Democrats, Republicans and even ideas utilized in states across the nation.

despite constraints that are both political and self-imposed, we believe that it is quite possible to reduce unnecessary and wasteful spending throughout the New Mexico budget. In order to provide a guide for policymakers, the Rio Grande Foundation has compiled a list of specific budget reduction ideas.

Establish limited priorities for Oklahoma’s state government. Once limited priorities are set, everything else should be considered according to these priorities. The state currently has hundreds of agencies, boards, and commissions; it’s no wonder there is chronic overspending and regular “revenue shortfalls.”

Replacing the current federal financing structure of Medicaid with fixed allotments to the states would help save both state and federal budgets. Without this policy change, states will dig further budgetary holes and the federal government will face an increased likelihood of a debt crisis.  If states received a non-fungible Medicaid block grant from the federal government rather than fungible matching funds, each state would have the incentive to reign in Medicaid spending.  If states were freed from the myriad federal mandates (such as the “maintenance of effort” clause of the Patient Protection and Affordable Care Act) they would gain the ability to run Medicaid efficiently.

Incremental policy changes are not sufficient to address the projected doubling of costs every decade. Texas now has the opportunity to reform the state's Medicaid program for the better. Reform must be carefully designed to ensure against recreating the same problems that have plagued Medicaid since its inception: rising caseloads and mandated benefits.

Medicaid, the joint federal/state program that was created to provide health care for the poor, celebrated its 40th birthday in 2006. There was no party for the program, however. In Pennsylvania and around the nation, Medicaid is growing at an unsustainable rate and threatens both state and federal budgets.

Louisiana governor Bobby Jindal, and Health Secretary Alan Levine, both veterans of Medicaid reform, have developed a plan based on key reforms such as accountability, consumer choice, cost efficiency, marketplace competition, and transparency.

Personal shopping and cleaning services for the disabled would be eliminated, weak hospitals could be merged and brand-name drugs would be limited under a series of budget-cutting proposals announced by the New York State Health Department.

The document explains why and how New York state developed such massive budget deficits and identifies programmatic changes to begin closing the gaps, including privatization and competitive contracting, cost reductions and tax policy goals to promote economic growth.