To date,1 32 states and the District of Columbia have expanded Medicaid under the Affordable Care Act (ACA) to adults with incomes at or below 138% of the federal poverty level (FPL)—newly covering more than 12 million Americans by the end of 2015. Nearly all of these states expanded in 2014 and 2015, while Louisiana and Montana were “late expanders” in 2016. Maine was the latest state to expand, when voters approved Medicaid expansion as a ballot initiative in November 2017. States’ inactivity last year on the expansion front likely resulted from congressional efforts to repeal the ACA, but since the failure of repeal and replace, some states and stakeholders are now refocusing on expansion. Fueling this renewed attention is the growing body of evidence that expansion brings measurable health and economic benefits to states, the continued availability of enhanced federal funding to expand, and new flexibility under the Trump Administration to permit work requirements and other new eligibility conditions for expansion adults.

Current Medicaid Expansion Efforts

Current state efforts to expand Medicaid are very much responsive to a state’s policy priorities and political environment.

Legislation: The Trump Administration’s promised flexibility for state Medicaid programs has encouraged additional state legislatures to consider authorizing Medicaid expansion, while conditioning coverage on payment of premiums and/or compliance with work and community engagement requirements.

  • After rejecting Medicaid expansion for several years, Virginia’s Republican-led legislature is on the cusp of passing Medicaid expansion, which would extend Medicaid to as many as 400,000 Virginians.2 November’s election of Governor Ralph Northam (D), who campaigned on a promise to expand Medicaid, has been a key factor in driving the state’s momentum, as have the gains that Democrats made in the House of Delegates last November. Republicans now have a one-vote majority in both the state’s House and Senate, with Lieutenant Governor Justin Fairfax (D) positioned to cast tie-breaking votes in the Senate. The Trump Administration’s willingness to permit states to condition Medicaid eligibility on work and implement lockouts for failure to make timely premium payments also has been a key factor in shifting the status quo in Virginia. Against this backdrop, the House of Delegates passed budget bills (during the regular legislative session and again in the current special session) that include both an expansion proposal and work requirements, as well as a requirement to fund the non-federal share with a provider tax. Now, the action is focused in the Senate, where two Republican senators declared their support for expansion with the condition that it be paired with work requirements, giving the Senate enough votes to pass a budget. The state must pass its budget by July 1 to avoid a government shutdown.
  • On March 27, Utah Governor Gary Herbert (R) signed H.B. 472, a bill expanding Medicaid eligibility to over 72,000 adults ages 19 to 64 with incomes at or below 100% FPL; the expansion is contingent on Utah receiving federal approval of an enhanced federal medical assistance percentage (FMAP) for the expansion group, even though eligibility would extend to 100% FPL and not to 138% FPL.3 The Obama Administration took the position that partial expansions with enhanced FMAP were not permitted under the ACA; the Trump Administration has not yet opined on partial expansions. As part of its June 2017 request to add work requirements to its expansion waiver, Arkansas requested approval for a partial expansion with enhanced FMAP. The Centers for Medicare & Medicaid Services (CMS) approved the work requirements in March 2018, but did not make a decision on the question of partial expansion, which would have reduced the state’s expansion eligibility level from 138% FPL to 100% FPL. Massachusetts also has a request for partial expansion pending. Like Arkansas, the state seeks to reduce its eligibility level for the Medicaid expansion population to 100% FPL but, unlike Arkansas, would use Medicaid funding at the regular federal match rate to “wrap” premium and cost-sharing subsidies for these and other Marketplace enrollees with incomes up to 300% FPL, already authorized under the state’s current 1115 demonstration. Meanwhile, Utah Decides Healthcare—a citizen-organized ballot initiative—has secured enough signatures to put Medicaid expansion on the ballot in November. If the expansion passes, Utah would be required to expand Medicaid up to 138% FPL, extending coverage to approximately 150,000 low-income Utahns.4

Ballot Referendum: Last year, Maine became the first state to approve Medicaid expansion through a ballot initiative. However, Governor Paul LePage (R) has refused to implement the expansion, and on April 30, healthcare and consumer advocacy groups—led by Maine Equal Justice Partners—and five Mainers who would qualify for Medicaid under the expansion filed a lawsuit against the Maine Department of Health and Human Services, seeking to compel the state to implement Medicaid expansion. Despite the delay in implementation, Maine’s ballot initiative has served as a model for stakeholders in other states, including Idaho, Nebraska, Montana and Utah (as described above).

  • By Idaho’s April 30 deadline, Reclaim Idaho stated it had gathered more than 60,000 signatures (approximately 4,000 more than the minimum 56,192 signatures required) for a November ballot initiative about whether to expand Medicaid; Medicaid expansion would extend coverage to 78,000 Idahoans who now fall in the coverage gap.
  • In Nebraska, organizers of the “Insure the Good Life” petition have been collecting signatures since early April to put a Medicaid expansion proposal on November’s ballot. They have until July 5 to collect 85,000 signatures. Expansion would extend coverage to an estimated 90,000 low-income Nebraskans.
  • A community-led coalition, Healthy Montana, also has launched an initiative to include Medicaid expansion on Montana’s ballot this November, but Montana is in a different position than Idaho, Nebraska, Utah, and other states that have yet to expand. The Montana legislature expanded Medicaid in 20155 and must reauthorize expansion before it expires on June 30, 2019. Governor Steve Bullock (D) has championed the benefits of expansion in Montana—including the state savings, increased workforce participation, and coverage for more than 90,000 Montanans—and plans to work with the state’s legislature on reauthorization. However, given the uncertainty around whether the legislature will reauthorize expansion in 2019, a coalition of healthcare and other groups has launched Initiative 185 (I-185) to put a proposal to extend Medicaid expansion on November’s ballot. I-185 seeks to fund the expansion by raising tobacco taxes. To qualify the initiative for the ballot, Healthy Montana for I-185 must gather at least 25,468 signatures by June 22.

Conclusion

As long as the ACA remains law, the incentives to expand—generous federal funding and the opportunity to reduce the ranks of the uninsured while realizing state budget savings—will remain compelling for some states. With CMS under the Trump Administration willing to give states some of the program flexibilities for which they have long advocated—especially for expansion adults—more states may consider expanding. Policymakers will be closely watching to see if CMS permits states to pursue partial expansion—a decision that would certainly nudge more states toward expanding, but also would likely result in some expansion states seeking to decrease their Medicaid eligibility levels. And, while all of these dynamics play out, consumer advocacy groups’ efforts to place expansion on the ballots in states such as Idaho and Nebraska may inspire similar efforts in other states.