Obamacare’s Medicaid Expansion Is Helping The Uninsured — Where It’s Allowed To

How the Supreme Court and bitter partisanship over Obamacare are letting Red America slip further behind while Blue America moves forward.

By Jeffrey Young, Nicky Forster, Hilary Fung and Alissa Scheller

WEDNESDAY, OCT. 7, 2015, 8:00 AM EDT

The Affordable Care Act’s chief aim is to extend coverage to people without health insurance. One of the 2010 law’s primary means to achieve that goal is expanding Medicaid eligibility to more people near the poverty level. But a crucial court ruling in 2012 granted states the power to reject the Medicaid expansion.

As a consequence, a two-tiered health care system is taking deeper root in America. In mainly Republican-led, Southern states, the uninsured rate remains disproportionately high. In sharp contrast, the ranks of the uninsured are falling sharply in states — most run by Democrats — that expanded Medicaid.

CheckmarkObamacare’s Medicaid Expansion Spreads


states adopted expansion

States in
blue have expanded Medicaid.

Medicaid is a health care program for low-income people created in 1965. It is jointly managed and financed by the federal government and the states. More than 70 million Americans are enrolled in Medicaid or the Children’s Health Insurance Program, a related benefit.

Medicaid mainly covers children, pregnant women, some parents of poor kids, people with disabilities and elderly nursing home patients. Before the Affordable Care Act, adults who had no children living at home or who didn't have a disability were usually excluded, no matter how poor they were.

President Barack Obama signs the Affordable Care Act. The law includes the largest expansion of Medicaid coverage for poor adults in the program’s history. The ACA creates a new minimum standard allowing legal U.S. residents with incomes just above the poverty level to enroll in the program. The federal government will cover no less than 90 percent of the new spending.

Five states and the District of Columbia begin phasing in the expansion early during 2010 and 2011.

The Supreme Court rules 7-2 that states may opt out of the law’s Medicaid expansion without losing previous federal funding. The decision leaves millions of poor residents without health coverage in states that decide to reject broader Medicaid eligibility.

Mobile map 1
States in
blue have expanded Medicaid.

Over the course of 2013, a number of states pass bills or take administrative steps to accept the ACA’s Medicaid expansion, which will take full effect on Jan. 1, 2014. Most of these states are run by Democrats, who adopt the policy with little fanfare. But a handful of Republican governors, starting with Brian Sandoval of Nevada, also announce their support.

Arkansas Gov. Mike Beebe (D) strikes a compromise with the majority-Republican legislature to pass the “private option,” a version of the Medicaid expansion that uses federal money to subsidize private insurance. This inspires the adoption of similar plans in states with Republican leaders and divided governments.

Arizona Gov. Jan Brewer (R) muscles a Medicaid expansion through the legislature, prompting a still-unsettled legal challenge from angered Republican legislators.

Iowa and Michigan follow Arkansas’ lead when their Republican governors and legislatures enact privatized variations of the Medicaid expansion.

Ohio Gov. John Kasich (R) circumvents the Republican majority in the legislature and expands Medicaid via an obscure budgetary mechanism, a maneuver later affirmed by the state Supreme Court.

Medicaid coverage becomes available to newly eligible residents of states that joined the ACA’s expansion.

Debate over Medicaid expansion continues across the country in 2014 and 2015.

After a prolonged fight with the majority-GOP legislature, New Hampshire Gov. Maggie Hassan (D) signs a privatized Medicaid expansion into law.

Gov. Tom Corbett (R) of Pennsylvania, a former Medicaid expansion opponent, signs a privatized version of the policy into law. Six months later, his Democratic successor, Tom Wolf, scraps it and begins moving enrollees into standard Medicaid.

The majority-Republican legislature and Montana Gov. Steve Bullock (D) agree on a privatized expansion of Medicaid. A year earlier, Medicaid expansion legislation had nearly passed, but a Democratic lawmaker accidentally voted against the bill, leaving it one vote short. Federal authorities haven’t yet approved Montana's plan.

Indiana Gov. Mike Pence (R) and the Republican legislature enact the most conservative version of Medicaid expansion to date, which requires enrollees to shoulder more of their medical costs than under the traditional program.

Gov. Bill Walker (I) of Alaska ends months of fruitless negotiations with Republican legislators and expands Medicaid under his own authority, an action GOP lawmakers challenge in court.

Elected officials in states including North Carolina, South Dakota, Tennessee, Utah, Virginia and Wyoming continue to debate Medicaid expansion. In Texas and other states, mostly in the South, expansion appears dead for now.

Mobile map 2
States in
blue have expanded Medicaid.

The history of Medicaid suggests the expansion will continue to spread. When the program launched 50 years ago, just over half the states signed up in the first two years. The last state to join, Arizona, didn’t begin participating until 1982.

PeopleA Tale Of Two Americas

The states that expanded Medicaid already had a lower combined uninsured rate than the states that didn’t, and the gap has widened since then. States that undertook the expansion experienced significantly larger increases in the share of their residents with health coverage, compared to states that rejected the expansion and relied only on federally subsidized private health insurance from the exchange marketplaces to expand coverage.

In non-expansion states, people below the poverty level get no help, because private insurance subsidies are available only to people who earn more than that.

Expansion states Non-expansion states 2013 Mid-Year 2015 2013 Mid-Year 2015 16.0% uninsured 8.9% 19.3% 14.2% Expansion states Non-expansion states 2013 Mid-Year2015 2013 16.0% uninsured 8.9% 19.3% 14.2% Mid-Year2015

Source: Gallup-Healthways Well-Being Index, August 2015

PillsWhere Your State Stands

Between December 2013 and June 2015, the national uninsured rate fell from 17.3 percent to 11.7 percent, Gallup reports. The decrease is much greater in states that expanded Medicaid, and the gap between the top and bottom states has grown.

States in
orange have not adopted Medicaid expansion.
Rhode Island 2.7%
Massachusetts 3.0%
Minnesota 4.6%
Vermont 4.6%
Connecticut 5.0%
Iowa 5.0%
Hawaii 5.2%
Wisconsin 5.6%
Ohio 6.1%
Washington 6.4%
North Dakota 6.9%
Maryland 7.0%
South Dakota 7.2%
Pennsylvania1 7.7%
New York 8.3%
West Virginia 8.3%
Michigan 8.5%
New Hampshire 8.7%
Illinois 8.8%
Oregon 8.8%
Kentucky 9.0%
Arkansas 9.1%
Maine 9.4%
New Jersey 9.7%
Delaware 9.9%
Texas 20.8%
Wyoming 18.2%
Oklahoma 17.7%
Louisiana 16.3%
Idaho 16.2%
Georgia 15.3%
Nevada 15.2%
Florida 15.2%
North Carolina 14.7%
Montana1 14.4%
Mississippi 14.2%
Utah 13.2%
New Mexico 13.1%
Tennessee 12.9%
South Carolina 12.6%
Virginia 12.5%
Alabama 12.0%
California 11.8%
Missouri 11.4%
Kansas 11.3%
Indiana1 11.1%
Colorado 10.6%
Arizona 10.5%
Alaska1 10.3%
Nebraska 10.0%

Source: Gallup-Healthways Well-Being Index, August 2015

1. Gallup did not classify Indiana, Montana and Pennsylvania as Medicaid expansion states because too little time had passed between these states adopting the policy and the survey, so enrollment would not be reflected in the findings. Alaska also is not categorized as an expansion state because it opted in after the survey period. Gallup excludes the District of Columbia from these polls. Methodology can be found on the Gallup site.