Obamacare’s Medicaid Expansion Slashed The Uninsured Rate — And The GOP Wants To Take It Away

Repealing The Affordable Care Act Would Undo Gains For Poor Families Across America


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 Supreme Court ruling in 2012 granted states the power to reject the Medicaid expansion, entrenching a two-tiered health care system in America, where the uninsured rate remains disproportionately high in mainly Republican-led Southern and Southwestern states.

Now, President Donald Trump and the Republican-led Congress are moving to repeal the Affordable Care Act and its Medicaid expansion, which would reverse historic gains in health coverage across the country.

A 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. From 2013 to 2016, the uninsured rate fell 48 percent in expansion states and 28 percent in states that opted out of the Medicaid expansion.

Expansion states

15.8% uninsured

Non-expansion states


Source: Gallup-Healthways Well-Being Index, February 2017. The margin of sampling error is ±0.2 percentage points, 19 times out of 20.

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.

If the Affordable Care Act were repealed, the national uninsured rate would rise, a trend that would hit hardest in those states that had more uninsured before the law.

Where Your State Stands

Between December 2013 and December 2016, the national uninsured rate fell from 17.3 percent to 10.8 percent. The decrease is much greater in states that expanded Medicaid, and the gap between the top and bottom states has grown.

Gallup reported the percentage of population uninsured throughout 2016 in states that expanded and did not expand Medicaid. For comparison, we added 2013 percentages for each state. (All states' uninsured percentages dropped between 2013 and 2016.)

Smallest Percent Uninsured

West Virginia6.1%
North Dakota6.9%
New York7%
Rhode Island7%
New Hampshire7.6%
New Mexico9%

Largest Percent Uninsured

North Carolina13.6%
South Carolina13.1%
South Dakota9.9%
New Jersey9.3%

1 Enrollment in Louisiana's expanded Medicaid program did not begin until June 2016. Some respondents were surveyed before expansion.

Source: Gallup-Healthways Well-Being Index, February 2017. The margin of sampling error is ±1 to ±2 percentage points for most states, but as high as ±3.5 percentage points for states with low populations like North Dakota, Wyoming, Vermont and Alaska.

The History Of The Medicaid Expansion

Medicaid is a health care program created in 1965 for low-income people. It is jointly managed and financed by the federal government and the states. Nearly 69 million Americans were enrolled in Medicaid as of November 2016.

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 usually were excluded, no matter how poor they were.

States in blue have expanded Medicaid.

0 states adopted expansion

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.

President Barack Obama wins re-election, enabling him to continue implementing the Affordable Care Act during his second term despite Republican calls for repeal.

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 legal challenge from angered Republican legislators that a court later rejects.

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.

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

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.

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 unsuccessfully challenge in court.

South Dakota Gov. Dennis Daugaard (R) reverses course and endorses the Medicaid expansion, but receives only tepid support from the legislature.

Newly elected Louisiana Gov. John Bel Edwards (D) enacts the Medicaid expansion shortly after taking office.

New Kentucky Gov. Matt Bevin (R) announces his plan for a conservative remake of his state’s Medicaid program, and threatens to rescind the expansion if the Obama administration doesn’t approve it.

Donald Trump is elected president on a platform that includes repealing the Affordable Care Act, a goal he shares with the Republican majority in Congress.

Following a post-election meeting with Vice President-elect Mike Pence, South Dakota Gov. Dennis Daugaard (R) drops his Medicaid expansion plan.

Republican governors including Charlie Baker of Massachusetts, Rick Snyder of Michigan, John Kasich of Ohio, Asa Hutchinson of Arkansas and Brian Sandoval of Nevada urge Congress to take care not to disrupt the Medicaid programs in their states by acting too swiftly to repeal the Affordable Care Act without a replacement in place.

The history of Medicaid suggests the expansion would continue to spread if the Affordable Care Act were left in place. When the program launched more than 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.

But repealing the Affordable Care Act would eliminate the federal funding that mostly finances the Medicaid expansion. States lack the resources to maintain this coverage without these dollars, meaning a large portion, at least, of those who’d enrolled under expansion would become uninsured.