An early complication in ACA implementation was the 2012 Supreme Court ruling that the federal government could not require states to expand Medicaid, thus leaving expansion up to the states. In the wake of this decision, about 33 states plus the District of Columbia have since expanded Medicaid
RAND analysis concluded that Medicaid expansion on the whole boosts state economies and benefits the poorest residents. Increases in insurance coverage were highest in states that chose expansion. Individuals who gained coverage through Medicaid filled nearly 80% more prescriptions and had lower out-of-pocket spending. A similar pattern appeared among individuals who had one of five chronic conditions.