Status of State Medicaid Expansion Decisions: Interactive Map
Published: Jul 23, 2021
To date, 39 states (including DC) have adopted the Medicaid expansion and 12 states have not adopted the expansion. Current status for each state is based on KFF tracking and analysis of state expansion activity.
Key States with Expansion Activity
|States||Summary of Activity|
|United States||Coverage under the Medicaid expansion became effective January 1, 2014 in all states that have adopted the Medicaid expansion except for the following: Michigan (4/1/2014), New Hampshire (8/15/2014), Pennsylvania (1/1/2015), Indiana (2/1/2015), Alaska (9/1/2015), Montana (1/1/2016), Louisiana (7/1/2016), Virginia (1/1/2019), Maine (1/10/2019 with coverage retroactive to 7/2/2018), Idaho (1/1/2020), Utah (1/1/2020), Nebraska (10/1/2020), Oklahoma (7/1/2021), and Missouri (Unknown).
Arizona, Arkansas, Indiana, Iowa, Michigan, Montana, Nebraska, New Hampshire, New Mexico, Ohio, and Utah have approved Section 1115 waivers to operate their Medicaid expansion programs in ways not otherwise allowed under federal law. Some of these Section 1115 waivers include work requirements, which the Biden Administration has recently begun the process of withdrawing.
|STATES THAT HAVE ADOPTED AND IMPLEMENTED EXPANSION|
|Arkansas||In April 2021, Governor Asa Hutchinson signed a bill passed by the Arkansas Legislature that would replace the state’s current Medicaid expansion program, Arkansas Works, with the Arkansas Health and Opportunity for Me (HOME) program, contingent on federal approval. Arkansas Home would allow expansion enrollees who comply with work requirements and monthly premiums to enroll in private marketplace plans while enrollees who opt out of these requirements would receive traditional fee-for-service Medicaid coverage. Arkansas Works is set to expire at the end of 2021 and has faced legal challenges.|
|Idaho||Enrollment in Medicaid coverage under expansion began on November 1, 2019, and coverage for these enrollees began on January 1, 2020. Following a successful expansion ballot measure in November 2018, in 2019 Governor Brad Little signed a bill passed by the legislature that directed the Idaho Department of Health and Welfare to seek waivers for multiple changes to the expansion program and specified that if the waivers were not approved by January 1, 2020, then all individuals up to 138% FPL will be enrolled in Medicaid. The state submitted four waivers at direction from this legislation; however, only one has been approved to date.|
|Kentucky||On December 16, 2019, newly elected Democratic Governor Andy Beshear signed an executive order rescinding the Kentucky HEALTH waiver that had been set aside by the court in March 2019. The waiver had included a number of provisions including a work requirement, monthly premiums up to 4% of income, and coverage lockouts for failure to timely renew eligibility or timely report a change in circumstances. Kentucky’s expansion program was originally implemented and continues to operate under state plan amendment (SPA) authority.|
|Maine||Maine implemented expansion on January 10, 2019. Maine adopted the Medicaid expansion through a ballot initiative in November 2017. After former Governor LePage delayed implementation of the expansion for months, new Governor Mills signed an executive order on her first day in office (January 3, 2019) directing the Maine Department of Health and Human Services to begin expansion implementation and provide coverage to those eligible retroactive to July 2018. CMS approved the state’s plan retroactive to July 2, 2018 on April 3, 2019.|
|Montana||On April 18, 2019, the Montana Legislature passed a bill (which was signed by Governor Bullock on May 9, 2019) to continue the state’s expansion program with significant changes until 2025. This action came after Montana voters voted down a measure on the November 2018 ballot that would have extended the Medicaid expansion beyond the June 30, 2019 sunset date and raised taxes on tobacco products to finance the expansion. The approved bill directs the state to seek federal waiver authority to make several changes to the existing expansion program, including adding a work requirement as a condition of eligibility and increasing the premiums required of many beneficiaries. Per the legislation, the state submitted a Section 1115 waiver proposal with these changes to CMS on August 30, 2019 and the request is pending.|
|Nebraska||Enrollment in Medicaid coverage under expansion in Nebraska began on August 1, 2020, and coverage for these enrollees began on October 1, 2020. Nebraska voters had approved a Medicaid expansion ballot measure in November 2018, and the state delayed implementation to allow time to seek a Section 1115 waiver to implement expansion with program elements that differ from what is allowed under federal law, including a tiered benefit structure that requires beneficiaries to meet work and healthy behavior requirements to access certain benefits. CMS approved this waiver on October 20, 2020. However, following a February 2021 letter from CMS moving to withdraw NE’s approved work requirements, on June 1, 2021, the state announced that it planned to withdraw this approved waiver and offer all expansion adults full benefits starting October 1, 2021.|
|Oklahoma||Enrollment in Medicaid coverage under expansion in Oklahoma began on June 1, 2021, with coverage for these enrollees beginning on July 1, 2021. Oklahoma voters approved a ballot measure on June 30, 2020 which added Medicaid expansion to the state’s Constitution. Language in the approved measure prohibits the imposition of any additional burdens or restrictions on eligibility or enrollment for the expansion population.|
|Utah||Medicaid coverage under expansion began on January 1, 2020. Following a successful Medicaid expansion ballot measure in November 2018, the state legislature took steps to roll back the full expansion by directing the state to submit a series of Section 1115 waivers. On December 23, 2019, CMS approved certain provisions in the state’s “Fallback Plan” waiver request to amend its Primary Care Network Waiver to expand Medicaid eligibility to 138% FPL, effective January 1, 2020; the approval also included work requirements for the newly expanded adult Medicaid population.|
|Virginia||The Virginia General Assembly approved Medicaid expansion as part of its FY 2019-2020 budget on May 30, 2018; Governor Northam signed the budget into law on June 7, 2018. Expansion coverage became effective under state plan amendment (SPA) authority on January 1, 2019 after enrollment began on November 1, 2018.|
|STATES THAT HAVE ADOPTED BUT NOT YET IMPLEMENTED EXPANSION|
|Missouri||On August 4, 2020, Missouri voters approved a ballot measure that added Medicaid expansion to the state’s constitution and required implementation of expansion coverage by July 1, 2021. However, on May 13, 2021, Governor Mike Parson announced that the state’s Department of Social Services (DSS) was withdrawing its state plan amendment (SPA) submission and would not implement expansion as scheduled due to a lack of funding: the ballot measure did not include a revenue source and the state legislature excluded the program from its FY 2022 budget. Subsequently on May 20, advocates filed a lawsuit against the DSS, arguing that the state’s refusal to expand Medicaid is unlawful per the initiated constitutional amendment and asking that the court require expansion to go into effect on July 1, 2021. On June 23, a circuit court judge ruled in favor of DSS, finding that the state’s refusal to expand Medicaid is not unlawful because the initiated amendment violated the state constitution by failing to provide a funding source. However, on July 22, the Missouri Supreme Court overturned this decision, finding that the initiated amendment did not violate the state constitution and instructing the lower court to enter a judgment in favor of the plaintiffs. Pending this judgment, the timeline for Medicaid expansion implementation remains unknown.
Under the American Rescue Plan Act’s incentive, Missouri could receive an estimated $1.1 billion in additional federal funds over the next two years for the traditional Medicaid program if the state implements the Medicaid expansion. Language in the initiated constitutional amendment prohibited the imposition of any additional burdens or restrictions on eligibility or enrollment for the expansion population.
|STATES THAT HAVE NOT ADOPTED EXPANSION|
|Florida||An initiative to put Medicaid expansion on the 2020 ballot was delayed by its organizing committee to the 2022 ballot.|
|Georgia||On October 15, 2020, CMS approved an 1115 waiver called Georgia Pathways to Coverage which extends Medicaid coverage to 100% FPL for parents and childless adults with initial and continued enrollment conditioned on compliance with work and premium requirements and other eligibility and benefit restrictions at the regular state match rate. Although coverage under this eligibility extension was set to begin on July 1st, 2021, the state delayed waiver implementation until at least August 1, 2021 following the Biden Administration’s steps to withdraw waivers with work requirement provisions.|
|Kansas||Democratic Governor Laura Kelly included Medicaid expansion in her proposed budget for State Fiscal Year (SFY) 2022; however, the Republican-controlled legislature did not include expansion in its final budget. Separately, in February 2021 Governor Kelly had proposed Medicaid expansion legislation similar to a bipartisan Medicaid expansion bill introduced in January 2020 with premiums and a work referral program, funded with revenue from medical marijuana sales and taxes rather than with a reinsurance program and hospital surcharge as proposed in the 2020 bill. On May 26, the 2021 legislative session adjourned without any additional action on Kelly’s bill.|
|Mississippi||Although Mississippi’s Secretary of State approved a 2022 Medicaid expansion ballot initiative for circulation in April 2021, on May 19 the organizing committee suspended its campaign following a Mississippi Supreme Court decision ruling that the state’s entire ballot initiative process is inoperable due to procedural errors regarding ballot initiative language in the state’s constitution. While Medicaid expansion was a key issue in the 2019 Mississippi gubernatorial election, current Republican Governor Tate Reeves opposes expansion, making it unlikely that the state will take up expansion through legislation.|
|North Carolina||On March 24, 2021, Democratic Governor Roy Cooper included Medicaid expansion in his biennial state budget proposal for State Fiscal Years (SFY) 2022-2023. The budget assumes that the estimated $1.3 billion for the state’s share of expansion would be more than offset with federal dollars under the incentive in the American Rescue Plan. In 2019, Governor Cooper vetoed the SFY 2020-2021 budget passed by the Republican-controlled legislature due to omission of Medicaid expansion, and the 2019 legislative session resulted in a budget impasse. In August 2020, Governor Cooper once again included Medicaid expansion in his proposal for coronavirus-related adjustments to the FY 2020-2021 budget, but the legislature has not included expansion in any of its coronavirus relief bills.|
|South Carolina||On December 12, 2019, CMS approved two separate 1115 waivers for South Carolina which would extend Medicaid coverage from 67% to 100% FPL for its parent/caretaker relative groups and a new targeted adult group with initial and continued enrollment conditioned on compliance with work requirements at the regular match rate. Recently, the Biden Administration has begun to withdraw waivers with work requirement provisions.|
|South Dakota||In November 2020, South Dakota’s Secretary of State approved two 2022 Medicaid expansion ballot initiative petitions for circulation, both filed by the organizing committee Dakotans for Health. One is a constitutional amendment and the other is an initiated state statute (the constitutional amendment requires roughly double the number of signatures). Separately, the organizing committee South Dakotans Decide Healthcare filed two similar petitions for the 2022 ballot in February 2021, including an initiated constitutional amendment subsequently approved for circulation on March 25, 2021. Advocates have until November 2021 to gather the signatures.|
|Wisconsin||After the Wisconsin Legislature’s Joint Finance Committee voted to remove Medicaid expansion funding from Democratic Governor Tony Evers’ State Fiscal Years (SFY) 2022-2023 budget proposal, Governor Evers signed an executive order to hold a special session for Medicaid expansion legislation on May 25, 2021, proposing to use the additional federal funds the state could receive under the incentive in the American Rescue Plan Act for other state development projects. However, on May 25, the Republican-controlled legislature adjourned the special session without further action, and the legislature passed a SFY 2022-2023 budget without Medicaid expansion funding on June 30. The governor had included Medicaid expansion in his previous budget proposal for FY 2020-2021, but the Republican-controlled legislature did not include it in the final budget. Wisconsin covers adults up to 100% FPL in Medicaid but did not adopt the ACA expansion.|
|Wyoming||A Medicaid expansion bill that passed the Wyoming House for the first time subsequently failed a vote in the Senate Labor, Health, and Social Service Committee in March 2021. However, on May 11, 2021, the legislature’s Joint Revenue Committee voted to sponsor this bill and bring it back for debate during a separate session in the coming months. The bill would expand Medicaid contingent on the state continuing to receive a 90% federal match assistance percentage (FMAP) for the expansion population and at least 55% for the traditional Medicaid population (a 5 percentage point increase from the traditional match rate of 50%, which is an incentive included in the American Rescue Plan Act for adopting expansion). Prior to the new ARPA incentive, the Wyoming legislature had rejected multiple Medicaid expansion bills during the 2020 and other previous legislative sessions.|
Medicaid Expansion Resources
- New Incentive for States to Adopt the ACA Medicaid Expansion: Implications for State Spending
- Building on the Evidence Base: Studies on the Effects of Medicaid Expansion, February 2020 to March 2021
- The Effects of Medicaid Expansion under the ACA: Studies from January 2014 to January 2020
- Effects of the ACA Medicaid Expansion on Racial Disparities in Health and Health Care
- The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid
- Medicaid Expansion Enrollment and Spending Leading up to the COVID-19 Pandemic
- Medicaid: What to Watch in 2021
- Eliminating the ACA: What Could It Mean for Medicaid Expansion?
- Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State
- The Uninsured and the ACA: A Primer – Key Facts about Health Insurance and the Uninsured amidst Changes to the Affordable Care Act
- Medicaid State Fact Sheets
- An Overview of State Approaches to Adopting the Medicaid Expansion