Medicaid expansion a tough sell to governors of both parties

But DeCample said the governor has concerns that there be “state flexibility down the line.” So last week, Beebe asked officials at the federal Centers for Medicare and Medicaid Services whether, in the event of an unforeseen future fiscal calamity, Arkansas would be able to tighten its eligibility rules and still get the full federal match for those who continued to qualify for its Medicaid program.

To date, Beebe has received no answer.

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In a letter to the governors Tuesday, Sebelius assured them, “I appreciate that states have questions.” She gave little in the way of specific guidance, however, promising to address concerns at meetings in cities across the country beginning July 31.

Wisconsin’s secretary of health services, Dennis G. Smith, was skeptical. “I don’t think we’ll have answers anytime soon,” said Smith, who directed federal Medicaid operations under President George W. Bush and was appointed to his current post by Republican Gov. Scott Walker, a vocal critic of the health-care law.

Obama administration officials “are putting a brave face on all of this,” he said. “But they have a mess on their hands.”

Smith predicted that many states will ultimately interpret the rules in ways that conflict with the administration’s position.

“I suspect that judges are going to be hearing a lot of new cases as a result of this ruling,” he said. “I see legal challenges in the future.”

The earliest could be brought by the state of Maine.

Last spring, Maine’s legislature voted to eliminate Medicaid coverage for about 21,000 state residents. At the time, that unquestionably required the governor to seek a federal waiver from a “maintenance-of-effort” requirement in the health-care law that bars states from tightening their eligibility rules for Medicaid before 2014.

The Obama administration has signaled that it considers the maintenance-of-effort provision separate from the law’s expansion of Medicaid and therefore untouched by the Supreme Court’s ruling.

However, Adrienne Bennett, a spokeswoman for Maine Gov. Paul LePage (R), said the state attorney general has determined that the court’s ruling means Maine is no longer bound by the maintenance-of-effort mandate.

Bennett said that within a few weeks, the governor will file what effectively amounts to a pro-forma notice informing the Obama administration of Maine’s plan to alter its Medicaid program.

And if Obama officials object?

“The governor has indicated that he is willing to proceed with legal action,” she said.

Sarah Kliff contributed to this report.