- Thirty-eight states and DC have expanded Medicaid under the ACA.
- Twelve states continue to refuse to adopt Medicaid expansion, despite the fact that the federal government will always pay 90% of the cost.
- Nearly 19 million Americans have gained coverage through the ACA’s Medicaid expansion.
- The uninsured rate, particularly among low-income residents, is considerably lower in Medicaid expansion states.
What is Medicaid expansion?
A provision in the Affordable Care Act (ACA) called for expansion of Medicaid eligibility in order to cover more low-income Americans. Under the expansion, Medicaid eligibility would be extended to adults up to age 64 with incomes up to 138% of the federal poverty level (133% plus a 5% income disregard).
Pre-ACA, Medicaid was generally never available to non-disabled adults under age 65 unless they had minor children. And even then, the income caps to qualify as a parent/caretaker were very low. By expanding Medicaid, the ACA created a viable pathway to coverage for millions of low-income adults.
Why are there some states that haven't implemented Medicaid expansion?
The ACA called for Medicaid expansion nationwide. But in June 2012, the Supreme Court ruled that states could not be forced to expand their Medicaid programs, so it was left to each state to determine whether to participate or not.
When Medicaid expansion first took effect in 2014, it was only available in 26 states and DC. In the ensuing years, there has been a slow but steady increase in the number of states implementing Medicaid expansion. As of 2021, Medicaid had been expanded in 38 states and the District of Columbia (see list below).
Note that Missouri is counted among those 38 states. Missouri’s Medicaid expansion was slated to take effect in July 2021, but was delayed when GOP lawmakers refused to provide funding. A lawsuit ensued, and the state Supreme Court ruled that Medicaid expansion must be implemented as approved by the state’s voters in 2020. As of August 2021, the state is accepting Medicaid enrollment applications from newly eligible adults, but has said that they won’t be processed until October 2021.
But Wisconsin is not counted among the Medicaid expansion states. It has implemented what essentially amounts to a partial expansion of Medicaid, and has not coverage gap (described below) because Medicaid is available to low-income adults with income below the poverty level. But because Wisconsin has not fully expanded Medicaid as called for in the ACA (ie, Medicaid is not available in Wisconsin to adults with income between 100% and 138% of the poverty level), the state does not receive the enhanced federal Medicaid funding that it would receive if it fully expanded Medicaid.
How is Medicaid expansion funded?
The federal government is financing most of the cost of expanding Medicaid, and a small portion is being paid by participating states. The costs for enrollees who are newly eligible under the expanded guidelines were covered 100% by the federal government until the end of 2016. The states then gradually started paying a portion of the cost, reaching 10% by 2020.
The funding will remain at the 90/10 split going forward, with the federal government always paying 90% of the cost of covering the population that became newly eligible due to the expansion of Medicaid.
The states that refuse to expand Medicaid only receive their normal federal Medicaid funding, rather than the enhanced 90% funding that they would receive to cover the newly eligible population if they were to expand coverage (in the Medicaid expansion states, the normal federal funding still applies for the populations that were already eligible pre-expansion).
As noted above, the federal government does not provide this funding unless a state fully expands Medicaid. So Wisconsin continues to receive its normal federal match for Medicaid funding, and Utah was unable to secure Medicaid expansion funding until Medicaid was fully expanded (Utah initially implemented a partial expansion of Medicaid, but did not receive enhanced federal funding for it).
How many people are enrolled in coverage due to Medicaid expansion?
As of 2019, official Medicaid data put the total newly eligible enrollment at about 10 million. But the COVID pandemic drove the enrollment numbers significantly higher: As of 2021, there were about 14.8 million Medicaid enrollees who had gained eligibility due to Medicaid expansion, plus another 4 million who were already eligible for Medicaid under pre-ACA rules, but who had enrolled due to outreach and enrollment assistance efforts since the ACA was implemented.
Total enrollment in Medicaid/CHIP has increased by 42% since 2013, and that includes the dozen states that continue to reject federal funding to expand Medicaid.
What is the Medicaid coverage gap?
And according to US Census data, the percentage of people below the poverty level who are uninsured is more than twice as high in states that haven’t expanded Medicaid, compared with states that have. To be clear, this is due to the decisions that their states have made, rather than a flaw in the ACA itself. The states could opt to accept federal funding to expand Medicaid at any time, thus closing the coverage gap.
Five states — Texas, North Carolina, Florida, Georgia, and Tennessee — account for the lion’s share of the coverage gap population, and they are among the 12 states where expansion is still a contentious issue and the legislature and/or governor are still strongly opposed to accepting federal funding to expand Medicaid.
For people in the coverage gap who have received unemployment compensation for at least one week in 2021, the American Rescue Plan provided eligibility for premium subsidies. But this was a temporary provision, valid for 2021 only. Congressional lawmakers have been working to come up with a permanent federal solution for people in the coverage gap, but this is still a work in progress as of 2021.
Which states have expanded Medicaid?
As of 2021, Medicaid has been expanded in 38 states and DC (you can click on a state on this map for more information about each state):
- New Hampshire
- New Jersey
- New Mexico
- New York
- North Dakota
- Rhode Island
- West Virginia
Which states have refused to expand Medicaid?
As of 2021, the following states have not yet accepted federal funding to expand Medicaid:
- North Carolina
- South Carolina
- South Dakota
- Wisconsin (no coverage gap)