The Supreme Court ruling on the Affordable Care Act (ACA) allowed states to opt of the law's Medicaid expansion, leaving each state's decision to participate in the hands of the nation's governors and state leaders.
The Daily Briefing and American Health Line editorial teams have been tracking where each state stands on the issue since the ruling, combing through lawmakers' statements, press releases, and media coverage. In this latest iteration of our Medicaid map, we've determined each state's position based on legislative or executive actions to expand coverage to low-income residents using ACA funding.
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A state-by-state look at expansion
EXPANDING COVERAGE (26 STATES AND THE DISTRICT OF COLUMBIA)
- Arizona: On June 17, 2013, Gov. Jan Brewer (R) signed into law legislation that will expand Medicaid to an additional 350,000 people in the state. The signing came after Brewer called a surprise special session on the 2014 budget and Medicaid to try to resolve a deadlock among lawmakers on the two issues.
- Arkansas: Gov. Mike Beebe (D) on April 23, 2013, signed the state's expansion plan into law. Under the plan, Arkansas would accept the federal money for Medicaid expansion provided through the ACA but would use it to buy private insurance for about 250,000 eligible low-income residents. The federal government approved the plan in September 2013.
- California: Gov. Jerry Brown (D) on June 27, 2013, signed legislation that would expand the state's Medicaid program, Medi-Cal, to more than 1.4 million additional residents under the ACA.
- Colorado: Gov. John Hickenlooper (D) signed the expansion into law on May 13, 2013. He says that the expansion will save the state $280 million over 10 years and help cover an additional 160,000 adults.
- Connecticut: Gov. Dannel Malloy (D) was among the first governors to sign up for the Medicaid expansion after the ACA was enacted. The state was one of five states that opted to expand eligibility early.
- Delaware: Gov. Jack Markell (D) in January 2013 reiterated his support for the Medicaid expansion, including an additional $35.8 million for Medicaid in his FY 2014 spending plan. On July 1, 2013, Markell signed a FY 2014 budget plan that includes $29.8 million to "fund the State's Medicaid commitment."
- District of Columbia: D.C. Mayor Vincent Gray (D) in a statement on June 28, 2012, said, "The District is not at risk of losing any Medicaid funding as a result of [the Supreme Court] ruling, because District officials have already begun implementation of the ACA's Medicaid-expansion provisions and will continue to implement the expansion." D.C. sought permission from the federal government to expand its Medicaid program on May 13, 2010. The move expanded Medicaid to an additional 35,000 residents.
- Hawaii: Gov. Neil Abercrombie (D) has said his state will participate in the expansion. In a statement on June 28, 2012, Abercrombie said, "The Affordable Care Act is our ally in this effort" to "to support a healthcare system that ensures high quality, safety and sustainable costs." According to the Department of Human Services, the state is expanding Medicaid eligibility through the ACA.
- Illinois: Gov. Pat Quinn (D) signed Medicaid expansion into law on July 22, 2013. Approximately 342,000 low-income Illinois residents will be newly insured under the expansion.
- Iowa: On Dec. 12, 2013, Gov. Terry Branstad (R) announced that his administration and the White House had agreed on the final details of his plan to expand Medicaid. Two days earlier, CMS approved Iowa's alternate expansion proposal, which would allow the state to use federal funding under the ACA to help more than 100,000 low-income residents purchase private health coverage through the new Iowa Health and Wellness Plan. Branstad also proposed a small additional premium for certain beneficiaries. Under the agreement, Iowa will levy the additional premium on individuals with incomes exceeding 50% of the federal poverty level beginning in 2015. The state promised that it will not drop individuals' coverage if they fail to make payments.
- Kentucky: On May 9, 2013, Gov. Steve Beshear (D) said that expanding Medicaid is the right choice for Kentucky, noting that it would halve the number of uninsured in the state. He reiterated that sentiment in a Sept. 26, 2013, opinion piece in the New York Times. On Sept. 3, 2013, a federal judge cleared the way for the state to participate in the Affordable Care Act, ruling that the governor has the authority to expand Medicaid and establish an insurance exchange.
- Maryland: On May 5, 2013, Gov. Martin O'Malley (D) signed into law HB 228 to fully implement the Affordable Care Act.
- Massachusetts: On July 5, 2013, Gov. Deval Patrick (D) signed into law HB 3452, requiring Massachusetts to come into compliance with new federal regulations under the ACA. On July 12, 2013, Patrick signed into law the state's FY 2014 budget, which supports full implementation of the Affordable Care Act, including the Medicaid expansion.
- Michigan: On Sept. 3, 2013, the Michigan House voted 75-32 to grant final approval to a bill that would expand the state's Medicaid program beginning in April 2014. Gov. Rick Snyder (R) signed the bill into law on Sept. 16, 2013. The proposal contains cost-sharing provisions for Medicaid beneficiaries; it received federal approval in December.
- Minnesota: Gov. Mark Dayton (D) in February 2013 signed legislation that expanded Medicaid to an additional 35,000 childless, low-income adults in the state.
- Nevada: Gov. Brian Sandoval (R) in December 2012 became the first GOP governor to commit his state to expanding Medicaid under the ACA. According to Sandoval's announcement, nearly 78,000 Nevadans would be covered by the expansion.
- New Hampshire: On March 27, 2014, Gov. Maggie Hassan (D) signed bipartisan legislation (SB 413) to expand Medicaid coverage to an estimated 50,000 low-income state residents. Starting in April 2014, the state will move eligible residents into Medicaid programs. The plan then calls for enrolling those residents in private coverage options through the ACA insurance exchange in 2016, which would require a federal waiver. The law requires the state to receive that waiver by March 31, 2015; failure to do so would result in termination of the program three months later.
- New Jersey: Gov. Chris Christie (R) on June 28, 2013, signed a state budget that includes $227 million for Medicaid expansion in the state. However, he vetoed legislation that would have made the expansion permanent in the state.
- New Mexico: Gov. Susana Martinez (R) on Jan. 9, 2013, announced that the state would participate in the Medicaid expansion.
- New York: On June 28, 2012, in an announcement immediately following the Supreme Court's ruling on the ACA, Gov. Andrew Cuomo (D) said the state would participate in the expansion.
- North Dakota: Gov. Jack Dalrymple (R) in April 2013 signed legislation expanding Medicaid in the state.
- Ohio: The state's Controlling Board—a special bipartisan legislative panel—approved Medicaid expansion in 5-2 vote on Oct. 21, 2013, allowing Gov. John Kasich (R) to expand the program on Jan. 1, 2014, without approval from Ohio's Republican-controlled Legislature. Conservative lawmakers have pledged to mount a fierce legal campaign against the move.
- Oregon: The state has moved forward on Medicaid expansion with the support of Gov. John Kitzhaber (D). Starting on Jan. 1, 2014, state residents earning up to 138% FPL will qualify for Medicaid, up from 100% FPL in 2013.
- Rhode Island: On July 3, 2013, about one week before the state General Assembly adjourned for the year, Gov. Lincoln Chafee (I) signed a fiscal year 2014 budget measure that included a plan to expand Medicaid, which he endorsed in June 2012 and outlined in his 2014 budget proposal.
- Vermont: Health Care Access Commissioner Mark Larson in July 2012 said that Vermont would receive federal funds to expand its Medicaid program under the ACA. The expansion is expected to insure an additional 47,000 state residents.
- Washington: Gov. Jay Inslee (D) on June 30, 2013, signed a state budget that would expand Medicaid in the state.
- West Virginia: Gov. Earl Ray Tomblin (D) in May 2013 announced that the state would expand Medicaid, extending coverage to an additional 91,500 state residents.
CONSIDERING EXPANSION (4 STATES)
- Indiana: Gov. Mike Pence (R) on May 15 unveiled a plan to expand the Healthy Indiana Plan (HIP), an insurance program for low-income residents, as an alternative to expanding Medicaid under the Affordable Care Act. Indiana launched HIP in 2008 with a five-year federal waiver, billing it as the nation's first consumer-directed health plan for low-income residents. The program has been distributing Medicaid funds to eligible residents, each of whom gets $1,100 in an HSA-like account. The new proposal, which could extend access to HIP to as many as 500,000 people, requires federal approval.
- Missouri: Although Gov. Jay Nixon (D) favors expanding Medicaid, the General Assembly did not include funding for an expansion in the state's 2013 budget. Lawmakers in the state still are discussing whether to participate in the expansion. Missouri's House Interim Committee on Medicaid Transformation on Oct. 28, 2013, held a hearing to discuss Medicaid expansion, and discussed a model similar to the expansion model in Arkansas. However, legislation to expand the program in the state will not be considered until the 2014 session.
- Pennsylvania: On Sept. 16, 2013, Gov. Tom Corbett (R) unveiled a health reform package that includes a plan to improve access to Medicaid for hundreds of thousands of residents through a so-called premium assistance model. Under the model, as many as 520,000 eligible low-income residents would receive federal subsidies to purchase private coverage through the state's federally run insurance exchange, and federal Medicaid expansion funds would be used to help eligible residents purchase commercial insurance. The state Legislature has not yet acted on the proposal, which would require federal approval.
- Utah: Gov. Gary Herbert (R) on Jan. 23, 2014, announced that "doing nothing" on expansion was not an option and said the state will expand health insurance coverage to low-income residents. The state Legislature has endorsed two possible expansion plans: One plan would use ACA expansion funds to help eligible low-income residents purchase private coverage, and the other plan would offer subsidies to help eligible residents purchase private policies. However, Herbert has not yet indicated how he plans to expand Medicaid, and his final proposal may require approval from the federal government. Moreover, state House Speaker Becky Lockhart (R) has indicated that she would reject any expansion plan that relies on federal funding.
NOT EXPANDING AT THIS TIME (20 STATES)
- Alabama: On May 18, 2013, Gov. Robert Bentley (R) reiterated his opposition to expanding Medicaid, saying the state cannot afford it. Despite Democratic lawmakers declaring expansion to be one of their top goals for 2013, they failed to advance such legislation. According to a recent poll conducted by the Joint Center for Political and Economic Studies, two-thirds of state residents support expansion.
- Alaska: On Feb. 28, 2013, Gov. Sean Parnell (R) said that based on what he knows about the federal budget, he does not support Medicaid expansion and will not ask the state Legislature for funding or authorization to boost the program's eligibility limits. State Rep. Andy Josephson (D) in March 2013 introduced HCR 8, a resolution to compel the governor to take action on the expansion, but the resolution did not gain traction among Alaska lawmakers.
- Florida: On May 3, 2013, the Florida Legislature ended its session without granting final approval to a compromise measure that would have authorized an expansion of Medicaid, which Gov. Rick Scott (R) supports. No further action on expansion is expected this year.
- Georgia: Gov. Nathan Deal (R) on Jan. 16, 2013, confirmed he does not support Medicaid expansion. On March 28, 2013, both the House and Senate adjourned for the 2013 session. A bill to encourage Deal to consider expanding Medicaid died in the House in February 2013. Deal in May 2013 signed legislation creating the Joint Study Committee on Medicaid Reform, but it was "for the purposes of determining an appropriate plan for Medicaid reform," not specifically expanding the program under the ACA.
- Idaho: Gov. Butch Otter (R) on Jan. 7, 2013, in his state-of-the-state address said Idaho would not expand Medicaid. The state House and Senate both adjourned on April 4, 2013.
- Kansas: Gov. Sam Brownback (R) punted the decision on expanding Medicaid to state lawmakers, and the state Legislature wrapped up its session for the year on June 2, 2013, without taking action on any expansion proposals.
- Louisiana: On Feb. 6, 2013, Gov. Bobby Jindal (R) reiterated his opposition to expanding Medicaid in Louisiana. In an op-ed for the Washington Post, Jindal argued that the expansion would cost his state $1 billion over the first 10 years. The Louisiana Senate in May 2013 rejected an amendment that would permit state voters to decide on Medicaid expansion, effectively ending any possibility for action on the issue before the Legislature recessed for the year.
- Maine: On June 17, 2013, Gov. Paul LePage (R) vetoed a bill (LD 1066) that would have expanded the state's Medicaid program. LePage objected to the cost of expansion and also noted that previous hikes to Medicaid eligibility—which he termed "a massive increase in welfare expansion"—have not worked to reduce the number of uninsured in the state. Two days later, on June 19, 2013, House lawmakers failed to gain the two-thirds majority necessary to override the veto.
- Mississippi: Republicans in the Legislature in June 2013 blocked plans to expand Medicaid to an additional 300,000 state residents under the ACA.
- Montana: Republicans in the statehouse in April 2013 rejected plans to opt into the Medicaid expansion, which could have added another 70,000 state residents to the program.
- Nebraska: In May 2013, Republicans in the Legislature filibustered the Medicaid expansion, which is also opposed by Gov. Dave Heineman (R). The expansion could have extended Medicaid coverage to up to 80,000 residents.
- North Carolina: Gov. Pat McRory (R) on Feb. 12, 2013, announced that his state would not participate in the Medicaid expansion. McRory also signed legislation—passed in the House and Senate—confirming that the state would not participate.
- Oklahoma: Gov. Mary Fallin (R) rejected the Medicaid expansion in November 2012 and has not proposed an alternate model for expanding insurance coverage for low-income state residents. However, some administration allies have said she has "not closed the door" on a possible, future plan to expand coverage.
- South Carolina: On March 12, 2013, the state House Republican majority rejected an expansion of Medicaid, opting instead to allocate $80 million in state and federal funding in South Carolina's budget for a hospital incentive payment program. Gov. Nikki Haley (R) announced in July 2012 that she opposes expansion.
- South Dakota: In an interview with the Associated Press on Oct. 25, 2013, Gov. Dennis Daugaard (R) said he is leaning against expanding Medicaid. He said he will ask the Legislature to hold off on any Medicaid expansion plans until there is more evidence on how the ACA is working nationally.
- Tennessee: During brief remarks to reporters on Oct. 30, 2013, Gov. Bill Haslam (R) said that the state has been engaged in discussions with the federal government for a possible expansion of TennCare, the state's Medicaid program. However, those talks have slowed, and Haslam said that a decision with the government on an expansion plan is not expected before the New Year.
- Texas: Gov. Rick Perry (R) and the Republican majority in the state Legislature have unanimously rejected the Medicaid expansion, although Democrats have introduced legislation (HB 3791) that would establish a strategy to expand Medicaid. The bill is pending in the House.
- Virginia: In March 2013, Gov. Bob McDonnell (R) sent a letter to HHS Secretary Kathleen Sebelius stating that he and the state's General Assembly have agreed not to expand Medicaid under the ACA. The letter said that the state will not consider participating in the expansion unless there are "dramatic, verifiable cost-saving reforms of the program." However, on Nov. 5, 2013, Terry McAuliffe (D) was elected governor; he supports Medicaid expansion and could move forward a plan to expand the program in the state in 2014.
- Wisconsin: Gov. Scott Walker (R) on Feb. 13, 2013, said Wisconsin will not participate in the ACA Medicaid expansion, but will pursue its own strategy to expand health coverage across the state. In addition, the legislature's Joint Finance Committee in June 2013 voted against the expansion.
- Wyoming: Gov. Matthew Mead (R) in December 2012 said that he would not support Medicaid expansion in Wyoming. On January 31, 2013, the state Senate struck down a bill that would have expanded Medicaid.
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