Haris Ashley
The Affordable Care Act (ACA) permits states to expand Medicaid coverage to adults with incomes up to 138% of the poverty level. As of early 2022, more than 35 million people have enrolled in coverage related to the ACA, with a record-breaking 21 million people in over 40 states and territories gaining healthcare coverage thanks to the expansion of Medicaid to low-income adults under 65. States that have expanded their Medicaid programs have dramatically lowered their uninsured rates, with over 10 million low-income individuals gaining insurance.
| Characteristics | Values |
|---|---|
| Total number of people enrolled in Medicaid expansion | 21 million |
| Total number of people enrolled in Medicaid expansion, Marketplace coverage and the Basic Health Program | 35 million |
| Number of people who gained insurance because of Medicaid expansion | 10 million |
| Number of states that have adopted the expansion | 40 |
| Number of states that have not expanded their Medicaid programs | 12 |
| Number of people who could gain coverage if the 12 states expanded their Medicaid programs | 4 million |
| Number of people who gained coverage under the Biden-Harris Administration | 2 million |
| Number of people in the coverage gap with disabilities | 26% of adults aged 55-64; 10% of adults under 25 |
| Number of people in the coverage gap who are people of color | 60% |
| Number of people in the coverage gap who live in Texas, Florida and Georgia | 75% |
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What You'll Learn
- Medicaid expansion has helped improve coverage and access to care for people with disabilities
- Expansion has produced net savings for many states
- Uninsured rates in non-expansion states are nearly twice as high as those in expansion states
- People without insurance have more difficulty accessing care
- Expansion has produced gains in food security, housing security, financial wellbeing, and child support
Medicaid expansion has helped improve coverage and access to care for people with disabilities
The Affordable Care Act (ACA) permits states to expand Medicaid coverage to adults with incomes up to 138% of the poverty level. While the ACA initially mandated that all states adopt the expansion, a Supreme Court ruling later made it voluntary. As a result, about half of the states have not expanded their Medicaid programs, leaving millions of low-income individuals without insurance.
In states that have expanded Medicaid coverage, individuals can qualify based on their income alone. If their household income is below 133% of the federal poverty level (calculated to be 138%), they qualify. This has dramatically lowered uninsured rates in these states. Research shows that the people who gained coverage have grown healthier and more financially secure, while long-standing racial inequities in health outcomes, coverage, and access to care have shrunk.
Medicaid expansion has also helped improve coverage and access to care for people with disabilities specifically. Among adults who gained Medicaid coverage through expansion, those with disabilities had larger improvements in full-year insurance coverage and use of primary and preventive care than those without disabilities. People with disabilities who live in expansion states are more likely to be employed than those in non-expansion states because many of them are able to enter the workforce or increase their earnings without losing their coverage.
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Expansion has produced net savings for many states
The Affordable Care Act (ACA) permits states to expand Medicaid coverage to adults with incomes up to 138% of the poverty level. As of 2023, 40 states and Washington, D.C. have adopted the expansion, with South Dakota and North Carolina being the latest additions.
Medicaid expansion has produced net savings for many states. Firstly, the federal government pays the majority of the cost of expansion coverage. From 2014 to 2016, the federal government paid 100% of the cost, with the federal share dropping gradually to 90% for 2020 and each year thereafter, leaving states to cover the remaining small share. Secondly, expansion generates offsetting savings. As more people have gained coverage, hospitals' uncompensated care costs have fallen, and, in some states, payments to hospitals to help cover those costs have also decreased. For instance, California saved $750 million in 2015 by reducing funding for a program that provided care to medically indigent adults who did not qualify for Medicaid. Thirdly, in many states, expansion raises revenue from the taxes that the state imposes on private health plans and providers. For example, Virginia did not expand Medicaid until 2019. After one year of expansion, cost savings attributable to Medicaid expansion were larger than expected, with the governor's amended budget including additional savings of $211.7 million.
However, it is important to note that the future of the ACA's Medicaid expansion is uncertain as Congress considers significant changes to Medicaid financing. Any cuts in federal funding for expansion enrollees would likely lead a number of states to rollback coverage.
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Uninsured rates in non-expansion states are nearly twice as high as those in expansion states
The Affordable Care Act (ACA) permits states to expand Medicaid coverage to adults with incomes up to 138% of the poverty level. As of 2025, 40 states and Washington, D.C. have adopted the expansion, with South Dakota and North Carolina being the latest additions in 2023.
States that have expanded their Medicaid programs have seen dramatic reductions in their uninsured rates. In these states, individuals can qualify for Medicaid based on their income alone. If a household's income is below 133% of the federal poverty level, they qualify for Medicaid. This threshold is calculated to be 138% of the federal poverty level, although a few states have a different income limit.
In contrast, non-expansion states have nearly double the uninsured rates compared to expansion states (14.1% vs 7.6%). This is because these states have limited Medicaid eligibility, leaving many adults without children, people of color, and those with disabilities without coverage. For example, all non-expansion states except Wisconsin do not offer Medicaid to adults without children, regardless of their income. As a result, 80% of the individuals in the coverage gap are adults without dependent children.
The high uninsured rates in non-expansion states have significant implications for access to healthcare. In 2023, almost one in four uninsured adults did not receive necessary medical treatment due to the cost. Uninsured individuals are also less likely to receive preventive care and treatment for major health conditions and chronic diseases.
Medicaid expansion has been crucial in improving coverage and access to care, particularly for people with disabilities. In expansion states, people with disabilities are more likely to be employed as they can enter the workforce or increase their earnings without losing their coverage.
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People without insurance have more difficulty accessing care
People without health insurance coverage are less likely to access care and more likely to delay or forgo it due to the costs involved. In 2023, nearly half (46.6%) of uninsured adults aged 18 to 64 reported not seeing a doctor or healthcare professional in the past 12 months, compared to 15.6% with private insurance and 14.2% with public coverage.
The lack of insurance coverage can lead to unaffordable medical bills, resulting in medical debt. Over six in ten (62%) uninsured adults report having healthcare debt, compared to 44% of insured adults. Uninsured individuals are also less likely to receive preventive care and treatment for major health conditions and chronic diseases. They may not have a primary care provider and may not be able to afford the necessary health services and medications.
Medicaid expansion has been linked to improved health outcomes, including lower mortality rates from cancer, cardiovascular disease, liver disease, and maternal mortality. States that have expanded their Medicaid programs have seen a significant decrease in uninsured rates. For example, as of 2024, 40 states and Washington, D.C., have expanded Medicaid, resulting in lower uninsured rates and improved health outcomes.
The Affordable Care Act (ACA) allows states to expand Medicaid coverage to adults with incomes up to 138% of the poverty level. The federal government pays the majority of the expansion coverage costs, while states cover a small share. This has resulted in net savings for many states, as expanding coverage reduces hospitals' uncompensated care costs.
However, it is important to note that even in states with Medicaid expansion, some individuals may still fall into a coverage gap. This includes adults with incomes above their state's Medicaid eligibility threshold but below the poverty level, making them ineligible for ACA Marketplace subsidies. Additionally, people with disabilities may not meet strict state or federal standards for disability and may struggle to access care.
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Expansion has produced gains in food security, housing security, financial wellbeing, and child support
The Affordable Care Act (ACA) has had a significant impact on the number of people gaining insurance due to Medicaid expansion. As of June 2019, about 12 million people were newly eligible for Medicaid under the ACA, with a total of 15 million enrolled in the ACA Medicaid expansion group.
The ACA Medicaid expansion has also led to gains in food security, housing security, financial wellbeing, and child support. Firstly, in terms of food security, the expansion has been associated with reductions in food insecurity among low-income populations. Secondly, regarding housing security, the expansion has contributed to lower rates of home evictions. Thirdly, the expansion has improved financial wellbeing by reducing the number of unpaid bills and the amount of debt sent to collection agencies, particularly in areas with a high proportion of low-income, uninsured individuals. Lastly, on the topic of child support, the expansion has resulted in larger increases in the payment of both past-due and current child support in expansion states compared to non-expansion states. Unmarried mothers with child support orders have received more support in states that expanded Medicaid.
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Frequently asked questions
As of early 2022, more than 35 million people enrolled in coverage related to the Affordable Care Act (ACA), with over 21 million people enrolling in Medicaid expansion coverage. This includes the more than two million people who gained coverage under the Biden-Harris Administration.
Medicaid expansion has helped improve coverage and access to care among people with disabilities, enabling them to lead healthier lives and have more employment options. It has also led to more continuous coverage, with disruptions in coverage decreasing by 4.3 percentage points.
As of 2023, 40 states plus Washington, D.C. have adopted the expansion, with South Dakota and North Carolina being the most recent additions. 12 states have yet to expand their Medicaid programs, including Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming.
In addition to expanding health insurance coverage and improving health outcomes, Medicaid expansion has been shown to have a range of other beneficial secondary effects. These include gains in food security, housing security, financial wellbeing, and child support.
