Yesterday's announcement that Pennsylvania will become the 27th state to expand Medicaid under the Affordable Care Act was closely watched in both healthcare and political circles, for it shows further accommodation to both local health needs and political considerations. Will Pennsylvania's deal with the Centers for Medicare and Medicaid Services be the last, coming after Arkansas and Iowa? Or is it a sign that Medicaid, which has always combined federal mandates with some local flavor, will continue to shift with the political winds in the states?