There is a tired note to Secretary Sebelius's December 10, 2012 letter to the states on timlines and terms for exchanges and market reforms under the ACA. You can see it for yourself here: http://cciio.cms.gov/resources/files/gov-letter-faqs-12-10-2012.pdf. It is true — as she points out–that negotiations have been underway about ACA implementation, on one issue or another, for more than two years. But I want to suggest that this will not all be resolved anytime soon. This will be a marathon and not a sprint.
Secretary Sebelius also sounds tired of negotiations over the possibility of phased-in or partial expansion of Medicaid to 133% of the federal poverty level. The latest FAQ format guidance to the states does indicate, though, that "[i]f a state that declines to expand coverage to 133% of FPL would like to propose a demonstration that includes a partial expansion, we would consider such a proposal to the extent that it furthers the purposes of the program, subject to the regular federal matching rate." The regular FMAP varies by state, of course, but in no instance even approaches 100%. Choices will have to be made.
This means that fifty flowers can bloom, but it will cost you.