These days it may defy all logic to believe that the costliest and most controversial parts of the Affordable Care Act will actually go into place.

Consider Medicaid expansion, widely considered to be a foundation for a broad extension of health benefits for low-income Americans.

We're more than two years away from the change that would open the doors to millions of Americans, especially childless adults, to be eligible for Medicaid. But you can sense the trouble ahead.

First, budget deficit cutters are hammering away at anything that will stall growth in federal debt. Medicare spending is clearly in the crosshairs, and Medicaid's turn likely will come up, too. Most of the enrollment expansion called for in the ACA is paid for by the feds.

Medicaid officials surveyed by Kaiser Family Foundation project a 29 percent increase in spending throughout the United States, a study released Oct. 28 reveals. They say the cumulative effect of two recessions and a decade of constrained spending has left no cushion for states.

Then there are the projected enrollment numbers. The Congressional Budget Office has offered a widely reported estimate that some 16 million Americans will be newly eligible for Medicaid by 2019 because of changes in eligibility. A new study out in October 2011 from Health Affairs offers different numbers, saying that the range of new enrollment could be 8.5 million to 22.4 million. That's a big range and one anyone in the industry would have a hard time planning for.

State governments, especially those under Republican control, are already chafing at the idea of expanding Medicaid knowing they'll eventually be paying for the bills as they tighten their belts in other areas. In Congress, Republican lawmakers are working to roll back the Medicaid expansion provisions of the ACA.

Rolling back expansion, however, would defeat the purpose of the ACA, which was to create a health system in which nearly everyone has coverage, ending the need for cost-shifting. Other alternatives for controlling cost would be the adoption of a limited benefits package for all non-disabled adults on Medicaid, and a unified national benefit program for those now known as dual eligibles, whose care coordination is often frustrated by the bureaucratic disconnects between Medicare and Medicaid.

Here at HealthLeaders-InterStudy, we often use Texas to illustrate the messy business of expanding Medicaid. It operates one of the stingiest programs in the country, and as a result, could see an expansion of at least 1.8 million (Kaiser Family Foundation).

Given the state of politics, budget crises and anger over spending, can we really see that happening in Texas

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