This is a study of why two seemingly similar governors made divergent decisions on expanding Medicaid under the Patient Protection and Affordable Care Act (ACA). Performing a case study of Governors John Kasich (OH) and Scott Walker (WI), I explore the roles played by electoral pressures, political party, governor's ideology, the state's policy heritage, stakeholder advocacy, and the economy in each governor's decision about whether to expand Medicaid. Electoral pressure was the most significant factor for both governors. I demonstrate that even Walker succumbed to state electoral pressures and expanded Medicaid, albeit in a manner unique to Wisconsin. He did this despite his emphatic national rhetoric rejecting Obamacare and expansion. Additionally, existing state political institutions drove each governor to decide in a manner unique to his state: previous Medicaid decisions in Wisconsin and direct democracy in Ohio provided additional pressures and divergent starting points. The remaining factors served less as a driving force behind the decision and more as a frame to justify the decision ex post facto. Case studies allow for a more complex view of how political pressures fit together; differences can be explained and expanded, and an enhanced understanding of political processes can be gleaned.