When, in 2012, the US Supreme Court held that Medicaid expansion sanctioned by the Affordable Care Act (ACA) was essentially optional for states, it ushered in a newly contentious state politics. States led by Republican governors and legislatures opposed to the ACA had to decide whether to accept extensive federal funding to expand Medicaid for citizens in their states who were earning up to 138 percent of the federal poverty level. This Report from the States focuses on Ohio, whose Republican governor successfully navigated the rancorous politics of Medicaid to expand the state's program in 2014. Working at odds with his own party and gaining praise from traditional political opponents for his leadership on the issue, John Kasich circumvented the state legislature, turning to the Controlling Board to bring about initial expansion. In the wake of Kasich's landslide reelection in 2014, the politics of expansion and reauthorization have given way to a pervasive discourse of “reform.” In this next phase Kasich has endorsed policy positions (e.g., cost sharing, a focus on “personal responsibility”) that reunite him with his party's more traditional view of Medicaid while continuing to emphasize the importance of expansion.