Medicaid Expansion during the Trump Presidency: The Role of Executive Waivers, State Ballot Measures, and Attorney General Lawsuits in Shaping Intergovernmental Relations

This article assesses developments in the first two years of the Trump presidency regarding implementation of the Affordable Care Act (ACA), with a focus on Medicaid policy. Trump administration officials relied on executive actions to chip away at various elements of the ACA and encouraged and granted state requests for waivers allowing work-requirements and other personal-responsibility rules for Medicaid beneficiaries. Governors and state attorneys general were actively involved in lawsuits that led to several federal court rulings blocking implementation of Medicaid work requirements as well as a ruling that re-opened the legitimacy of the entire ACA. Citizens and interest groups had a major impact at the ballot box by approving several ballot measures that expanded Medicaid in states where expansion was opposed by elected officials. These developments demonstrate how policy adjustments and disputes are worked out in the U.S. federal system in a polarized era, with Congress essentially a bystander and other institutions and actors coming to the fore and resulting in variable speed federalism characterized by different partisan trajectories of state implementation of national policies.