Although the Affordable Care Act initially called for all states to expand Medicaid by Jan. 1, the Supreme Court ruled states could decide for themselves whether to expand Medicaid. Click the map for more information on Medicaid expansion by state. Status of Medicaid expansion reflects states’ status as of March 4, 2014.
Data sources: U.S. Census Bureau (uninsured population by state), Henry J. Kaiser Foundation (number of residents eligible for Medicaid by state)
WASHNGTON – With several states still debating or challenging Medicaid expansion under the new health care law, the opportunity to obtain health care coverage is in limbo for more than 1 million poor Americans.
Under the Affordable Care Act, the federal government required states to expand Medicaid eligibility requirements by Jan. 1 in return for increased federal funding. If states did not expand Medicaid eligibility requirements, the law granted the federal government power to withhold money from states’ existing Medicaid programs. However, in June the Supreme Court ruled the Medicaid expansion requirement unconstitutional, saying states could opt out without retaliation from the federal government.
Nearly two months after the initial deadline, half of the states have expanded Medicaid. Of the other 25, eight are considering some form of expansion, while the other 17 have no plans to expand Medicaid eligibility requirements.
But those numbers look likely to change.
With a legal battle waging in Arizona – a state that expanded Medicaid initially but could undo the expansion in the near future – and state politicians debating expansion in seven other states, many low-income residents are still waiting to find out if the new law will give them the coverage President Barack Obama promised.
Health and Human Services Secretary Kathleen Sebelius said the situation is particularly troubling because states choosing not to expand Medicaid eligibility requirements also have some of the largest uninsured populations.
“That’s an outrage,” Sebelius said during a recent interview with HuffPost Live. “There’s a cost of doing nothing in those states.”
She singled out Texas, North Carolina, Georgia and Florida – all states with large populations of uninsured black and Latino Americans – as having a particular duty to expand Medicaid, the federal program that provides health care for the poor.
A total of 17 states have a percentage of uninsured residents higher than the national average; 12 of those 17 states have not expanded Medicaid.
Yellow dots indicate states not expanding Medicaid, while blue dots indicate states debating some form of Medicaid expansion. States in red have uninsured populations larger than the national average; states in green have uninsured populations smaller than the national average.
The federal government will pay the full cost of states’ Medicaid expansion at first, but by 2020 states will have to pay 10 percent of the expansion cost.
Sebelius said the federal funding promise gives governors no excuse not to expand Medicaid in their states.
However, some ACA opponents argue Medicaid expansion approaches the problem in the wrong way.
Edmund Haislmaier, a health policy expert at the conservative Heritage Foundation, says there are better ways for states to help people afford insurance, like creating more jobs so that more people will be able to buy insurance on their own. Medicaid expansion is the wrong solution, he said, and it places a big financial burden on states.
“The savings are front-loaded,” Haislmaier said on the phone from Utah. “So it may look attractive, it may look like you save money up front, but down the road it could wind up costing you.”
Haislmaier pointed to efforts by legislators in Utah, where he was speaking at the conservative Sutherland Institute about alternatives to Medicaid expansion in that state, as a potential alternative to Medicaid expansion. Lawmakers in the state announced a plan mid-February to create a Medicaid alternative that would provide some benefits to low-income residents. The program would cost Utah between $30 million and $35 million annually, far less than the hundreds of millions of dollars Medicaid expansion in the state would cost the federal government.
Before the ACA, Medicaid was available to children, parents, pregnant women, the disabled and the elderly whose income fell below a certain level determined, in most cases, by individual states. The ACA sought to standardize and grow the program by expanding Medicaid eligibility to all adults and children who fall below 138 percent of the federal poverty level – for single adults, an income lower than roughly $16,000 a year.
“The impact of the ACA at the very bottom of the income distribution is substantially smaller than would have been the case if the Supreme Court had ruled differently,” said Gary Burtless, one of the authors of a Brookings Institution study released January on the ACA’s effects on income inequality. Roughly 4 million people who live in states that chose not to expand Medicaid make too much to qualify for Medicaid but too little to qualify for ACA subsidies, leaving them unable to afford insurance.
Some states are looking to solve the coverage gap and take advantage of federal Medicaid money without putting more people into the actual Medicaid program. Iowa and Arkansas passed a version of expansion that uses federal Medicaid money to subsidize private insurance for low-income residents, a so-called private option. Several other states are considering similar solutions.
States to Watch
Arizona – Medicaid expansion faces a legal challenge
Republican lawmakers in Arizona are challenging the state’s law expanding Medicaid eligibility in court. They argue the law should not have been passed last summer without a supermajority – a state requirement for approval of any tax increases. A state superior court struck down the challenge, but the legislators are working with the Goldwater Institute, an Arizona conservative advocacy group, to appeal the ruling.
Arkansas – just voted to expand Medicaid into 2015
In April, Arkansas became one of the only states in the South to expand Medicaid eligibility requirements. The Arkansas legislature nearly did not extend the Medicaid eligibility into 2015, but finally passed a plan on March 4 to continue the expansion into the next year after weeks of gridlock. Arkansas and Iowa are the only states with a “private option” expansion model that uses federal Medicaid money to buy private insurance for low-income residents, although several other states are considering similar programs.
Indiana – seeking Medicaid funds for a state-run program
Indiana politicians, notably Republican Gov. Mike Pence, have resisted expansion of the federal Medicaid program but are looking to expand the state’s own insurance program for low-income Indiana residents, the Healthy Indiana Program, using Medicaid funds. The program does not provide as comprehensive coverage as Medicaid, in part because it lacks coverage for maternity care. On Feb. 21, Pence formally requested that the Department of Health and Human Services consider the proposal.
Missouri – Republican legislature resisting expansion
Missouri’s Republican-controlled state legislature blocked expansion of Medicaid eligibility requirements in early February against the wishes of Democratic Governor Jay Nixon. Later that month, a Republican legislator introduced a modified proposal that would expand Medicaid eligibility but only to low-income residents with jobs. The legislature has yet to vote on the new bill.
Nebraska – considering a “private option”
Lawmakers in Nebraska sent a Medicaid expansion bill out of committee Feb. 24 to be debated by the full unicameral legislature. It would use federal Medicaid money to help low-income Nebraskans afford premiums and copays from plans on the Affordable Care Act health insurance marketplaces.
New Hampshire – bipartisan deal looks likely to pass
New Hampshire legislators announced Feb. 6 they had forged a bipartisan deal to expand Medicaid in the state. Lawmakers are scheduled to vote on the bill in March.
Pennsylvania – “private option” backed by governor
In September, Republican Pennsylvania Gov. Tom Corbett announced a plan that would expand Medicaid in the state by allowing residents who qualify to select a subsidized plan through the online insurance marketplaces. A similar plan has already been implemented in Arkansas. The legislature has yet to act on Corbett’s proposal, although he mentioned it in his State of the State address in February.
South Dakota – weighing partial expansion
South Dakota legislators announced last week they were looking into a partial Medicaid expansion that would extend Medicaid coverage to those who fall below the poverty line. A full Medicaid expansion under the Affordable Care Act would include all residents who fall below 138 percent of the poverty line.
Tennessee – governor weighing expansion
Although Tennessee did not expand Medicaid eligibility requirements before the start of 2014, Republican Gov. Bill Haslam implied during his State of the State address earlier this month that he had not made a final decision about the program. “I’m hesitant to commit additional dollars to Medicaid when it’s already eating up so much of our budget,” he said. “But I also understand that the decision isn’t just as easy as standing here today and saying, ‘We’re not going to expand Medicaid.’ There are hospitals across this state, many of them in rural communities, that are going to struggle if not close under the health care law without expansion, and that’s not something to take lightly.”
Utah – tension over accepting federal money
Republican lawmakers in Utah State House announced a plan in mid-February to create a Medicaid alternative that would provide some benefits to low-income residents. The program is projected to cost Utah between $30 million and $35 million annually, far less than the hundreds of millions of dollars Medicaid expansion in the state would cost the federal government. Meanwhile, the State Senate and the governor have proposed plans that would involve taking some money from the federal government to help subsidize private insurance for low-income residents. The full Utah legislature has yet to vote on any of the proposals.
Virginia – state legislature considering “private option”
Virginia state senators February revealed a plan that would expand Medicaid in the state using a so-called private option, like those in place in Arkansas and Iowa. The plan would use federal Medicaid money to buy private insurance for low-income residents. The legislature has yet to vote on the proposal.
