Status of State Medicaid Expansion Decisions: Interactive Map
Published: Nov 06, 2019
To date, 37 states (including DC) have adopted the Medicaid expansion and 14 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), and Idaho, Nebraska, and Utah (to be determined).
Arizona, Arkansas, Indiana, Iowa, Michigan, Montana, New Hampshire, New Mexico, and Ohio have approved Section 1115 waivers to operate their Medicaid expansion programs in ways not otherwise allowed under federal law. Arkansas continues to operate its expansion program through a waiver, however, the waiver provisions related to the work requirement and reduction of retroactive eligibility were set aside by court on March 27, 2019.
|STATES THAT HAVE ADOPTED AND IMPLEMENTED EXPANSION|
|Kentucky||On March 27, 2019, the court set aside the reapproved Kentucky HEALTH waiver. In its previous decision, the court had set aside the original waiver approval, and on November 20, 2018, CMS reapproved the Kentucky HEALTH waiver with minor technical changes. Unless and until HHS issues another approval that passes legal muster or prevails on appeal, the work requirement, monthly premiums up to 4% of income, coverage lockouts for failure to timely renew eligibility or timely report a change in circumstances, heightened cost-sharing for non-emergency ER use, and elimination of retroactive eligibility and non-emergency medical transportation will not be implemented. The separate “institution for mental disease” substance use disorder payment waiver was not set aside and was allowed to go into effect. Kentucky’s expansion program was originally implemented and continues to operate under SPA authority. On November 5, 2019, Democratic Attorney General Andy Beshear claimed victory in Kentucky’s gubernatorial race. His opponent, incumbent Republican Matt Bevin, has not yet conceded the race. In his victory speech, Beshear vowed to rescind the Kentucky HEALTH waiver in his first week in office.|
|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.|
|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|
|Idaho||Idaho voters approved a ballot measure in November 2018 that requires the state to submit a state plan amendment (SPA) to the Centers for Medicare and Medicaid Services (CMS) to implement the Medicaid expansion within 90 days of approval of the measure. Idaho submitted a SPA for the Medicaid expansion in February 2019. On April 9, 2019, Idaho Governor Little signed a bill passed by the legislature that makes changes to the Medicaid expansion program approved by voters. The legislation directs the Idaho Department of Health and Welfare to seek waivers for multiple changes, including to add a work requirement as a condition of eligibility for coverage; implement a form of “partial expansion” in which the state would access the ACA enhanced match rate for the newly eligible population up to 100% FPL and individuals between 100-138% FPL who choose to opt-in to Medicaid coverage (the default for that population would be qualified health plan (QHP) coverage in the Marketplace with advance premium tax credits); and to use Medicaid funds to pay for substance use and/or mental health services in institutions for mental disease (IMDs). The legislation specifies that if the waivers are not approved by January 1, 2020, then all individuals up to 138% FPL will be enrolled in Medicaid.
On August 29, 2019, CMS rejected Idaho’s 1332 waiver request to access the ACA enhanced match rate for expansion-eligible individuals to stay on the state’s health insurance exchange rather than enroll in Medicaid. The Governor said that the state plans to resubmit the application with additional information. CMS, however, specified that even a revised application would not be approved as it could not demonstrate compliance with the deficit neutrality guardrail.
|Nebraska||Nebraska voters approved a Medicaid expansion ballot measure in November 2018 and the state submitted a state plan amendment (SPA) for the expansion on April 1, 2019. The SPA delays Medicaid expansion implementation until October 1, 2020 to allow time for the state to seek a Section 1115 waiver to implement expansion with program elements that differ from what is allowed under federal law.
On August 28, 2019, Nebraska Appleseed (the group that organized the Medicaid expansion ballot measure) filed a lawsuit asking the Nebraska Supreme Court to rule that Medicaid expansion must begin no later than November 17, 2019. The group argued that the state’s planned implementation date of October 1, 2020 violates Initiative 427, the Medicaid expansion law approved by ballot initiative. The Supreme Court refused to hear the lawsuit before lower court review, and Nebraska Appleseed will refile the case in district court.
|Utah||Since Utah voters approved a November 2018 ballot measure to adopt the ACA Medicaid expansion up to 138% of the FPL, the state legislature has taken steps to roll back the full expansion. The state enacted a law in February 2019 that amended the voter-approved ballot measure, requiring the state to submit a series of Section 1115 waiver requests limiting the expansion to 100% FPL, first at its regular matching rate and then requesting the enhanced federal matching rate of 90%. The first waiver, the “Bridge Plan,” was approved in March 2019, and allowed the state to implement a coverage expansion to 100% FPL beginning April 1, 2019, at the state’s regular matching rate. The approved waiver also included an enrollment cap and a work requirement. On July 31, 2019, Utah submitted to CMS its “Per Capita Cap” proposal for a new waiver that would continue a number of provisions already approved as well as a request for the enhanced match for partial expansion and a limit on enhanced federal funding. More details about the provisions of this waiver can be found in the Medicaid Waiver Tracker. CMS issued a statement in late July and a letter to the state in mid-August confirming that they would not approve the enhanced matching rate for an expansion that does not go to 138% FPL or that includes an enrollment cap.
On September 27, 2019, Utah released its “Fallback Option” waiver for public comment. This waiver seeks the enhanced federal match for coverage to 138% FPL and continues some other provisions in the earlier waivers, including a work requirement and monthly premiums. The state legislation requires Utah to submit this waiver to CMS if the Per Capita Cap waiver does not receive approval by January 1, 2020. If CMS does not approve the Fallback Option by July 1, 2020, Utah must adopt the full Medicaid expansion as required by the ballot initiative without the other waivers’ additional provisions.
|STATES THAT HAVE NOT ADOPTED EXPANSION|
|Florida||A recent Medicaid expansion ballot initiative effort was delayed by its organizing committee to the 2022 ballot. A resolution filed by Democratic State Senator Annette Taddeo on September 5, 2019 to put a constitutional amendment expanding Medicaid to a statewide vote is currently in committee but is likely to fail in the Republican-controlled legislature.|
|Georgia||On March 27, 2019, Republican Governor Brian Kemp signed The Patients First Act, which aimed to address challenges in healthcare including the state’s high uninsured rates. The bill authorized the Georgia Department of Community Health to submit a Section 1115 waiver request that could include a Medicaid expansion limited to coverage up to 100% FPL. The bill allocated funds which the Department used to contract with Deloitte to develop this waiver request as well as potential Section 1332 waiver requests. In accordance with the March legislation, on October 31, 2019, Kemp released a proposed 1332 waiver seeking to implement a reinsurance program and make other changes to marketplace coverage. On November 4, 2019 his office released a proposed 1115 waiver called Georgia Pathways to Coverage which would expand Medicaid coverage to 100% FPL and requests the enhanced ACA funding match despite a July statement from CMS indicating that it will not provide this match for partial expansions. Georgia Pathways also includes work requirements, premiums, and copayments. The state’s Department of Community Health will collect public comments on the waiver until December 3, 2019 and plans to submit the waiver to CMS on December 20, 2019. His office is expected to release a plan for Medicaid the following week.|
|Kansas||On September 4, 2019, Democratic Governor Laura Kelly signed an executive order establishing a council to prepare recommendations to guide an expansion bill in the Legislature in 2020. The council began meeting on September 30, 2019. Kelly ran for Governor on the issue of expansion in 2018, but Republican leaders blocked her expansion bill despite support from Democratic and moderate Republican legislators. An expansion plan passed in the House on March 20, 2019 but was blocked from coming to a debate or vote in the Senate. Senate Majority Leader Jim Denning proposed a version of Medicaid expansion on October 23, 2019. The Senate Select Committee on Healthcare Access recommended this proposal get further study in the 2020 legislative session.|
|Mississippi||Medicaid expansion was a key issue in the 2019 Mississippi gubernatorial election, dividing candidates in both the August 27 Republican primary and in the November 5 general election. Republican Lieutenant Governor Tate Reeves, who adamantly opposes expansion, ultimately won both races, making it unlikely that the state will take up expansion in the next four years.|
|Missouri||On September 4, 2019, Healthcare for Missouri announced its commitment to putting Medicaid expansion on the state’s 2020 ballot. To put the issue on the 2020 ballot, this campaign committee must submit about 172,000 valid signatures by May 3, 2020.|
|North Carolina||On June 28, 2019, Democratic Governor Roy Cooper vetoed the state budget proposed by the Republican-controlled legislature largely over the issue of Medicaid expansion. On September 11, 2019, Republican House Speaker Tim Moore held a successful veto override vote with 64 of the House’s 120 members present. The budget is now referred to the Senate, where one Democratic vote is required for an override (versus the seven House votes required had all members been present). Republicans in the Senate were unable to secure the votes necessary to override the veto before the legislature adjourned its session on October 31, 2019 without a new budget. No veto override votes will be held until at least January 2020, and the state will continue operating on the previous year’s budget. On September 18, 2019, the House Health Committee passed House Bill 655, a Medicaid expansion bill with work requirements and premiums; however, the House did not schedule any votes on this bill before the October 31 session adjournment.|
|Oklahoma||On July 29, 2019, the Oklahoma legislature announced the formation of the bipartisan Oklahoma Health Care Working Group tasked with developing a plan for increased health care and insurance coverage, which could include Medicaid expansion. In addition, the group Yes on 802 began circulation of their expansion ballot initiative on July 31, 2019. On October 24, 2019 the group submitted about 313,000 signatures, far exceeding the 177,958 required to put the issue on the 2020 ballot.||South Dakota||In May 2019, the group South Dakota Community Action submitted a Medicaid expansion ballot initiative measure to the state’s Legislative Research Council for review. On June 3, 2019, the Council responded that the measure satisfied the process for review and directed South Dakota Community Action to re-submit the final measure for a fiscal estimate.|
|Wisconsin||Wisconsin covers adults up to 100% FPL in Medicaid but did not adopt the ACA expansion.|
Medicaid Expansion Resources
- The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review
- An Overview of State Approaches to Adopting the Medicaid Expansion
- The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid
- Implications of the ACA Medicaid Expansion: A Look at the Data and Evidence
- Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State
- “Partial Medicaid Expansion” with ACA Enhanced Matching Funds: Implications for Financing and Coverage
- Explaining Stewart v. Azar: Implications of the Court’s Decision on Kentucky’s Medicaid Waiver
- Data Note: Data Do Not Support Relationship Between Medicaid Expansion Status and Home and Community-Based Services Waiver Waiting Lists
- The Uninsured: A Primer – Key Facts about Health Insurance and the Uninsured Under the Affordable Care Act
- Key Facts about the Uninsured Population
- Medicaid State Fact Sheets