Expanding Medicaid eligibility to all of the 13 million U.S. citizens who do not have medical insurance and earn up to 138% of poverty is projected to reduce their annual death rate 30% and prevent 44,789 premature deaths a year. However 21 states representing 6.3 newly eligible people have confirmed that they will NOT expand Medicaid eligibility and 5 more, representing 1.8 million more, have not yet made a decision, despite the fact that the federal government will pay 100% of the cost the first 3 years, and 90% on an ongoing basis. Is the failure to expand because of party politics? Is it sound economic analysis? Is it beliefs about the role of government? The answers are, of course, maybe not, and probably…but it is not as simple as I first thought.