In the wake of a 2012 Supreme Court ruling, states face complex decisions concerning 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. States must also factor in the strong likelihood that future federal support for Medicaid will be constrained relative to current law projections. Many states will thus find it prudent to defer their decision-making for as long as possible.