Governor Sophia is in a quandary. She believes everyone should have access to health care and would like to support state policies that make care accessible and affordable. While she supported President Obama’s goal of reducing the number of uninsured, she is concerned that some of the provisions in the Patient Protection and Affordable Care Act are too burdensome on the states, particularly in a fragile economy. The governor wonders how her state can afford the mandated Medicaid expansion when the recent trend has been to cut services across the board. How will state agencies cope with their new responsibilities when positions are being defunded and employees are being furloughed? Should she spend her state’s time and resources to establish a health insurance exchange when the federal government will step in if she does not act? At the same time, does she want to leave decisions about how the exchange will be operated in her state to bureaucrats in Washington, D.C.?