Medicaid Expansion Discussion in Selected States Twelve Years After ACA Passage

This week marks the twelve-year anniversary of the Affordable Care Act (ACA) but residents of twelve states still have not been able to access the Medicaid expansion benefit enacted as part of that law as their state leaders have blocked it from taking effect.  Over two million Americans are still unable to get quality, affordable health coverage because they live in one of the twelve states that have still refused to accept the huge federal funding available for Medicaid expansion created by the ACA. Over the last six months, there has been discussion at the federal level of passing changes to enable people in this category (who are largely working as cashiers, cooks, freight and stock laborers, waiters/waitresses, and nursing assistants or similar jobs where affordable health coverage isn’t available) to get temporary coverage. However, any action by Congress seems to have stalled for the moment. Meanwhile, there is significant movement on expanding Medicaid again in some states and lots of discussion in others:

South Dakota – What will voters decide?

Voters in South Dakota will decide if their state expands Medicaid on the ballot in November. Lawmakers briefly tried to derail momentum for voter-passed expansion with a bill of their own but that legislation recently failed. Lawmakers are attempting a second method to make it harder to pass expansion by asking voters in June to approve a change that would require a vote of at least 60% of South Dakota voters to approve Medicaid expansion as opposed to the simple majority required for all ballot measures.  Support for Medicaid expansion among voters is strong in the conservative state and South Dakotans are also leery of changes that make voter-initiated ballot measures on any subject more difficult to enact.

North Carolina – Bipartisan movement afoot

With a GOP led legislature and Democratic Governor Roy Cooper, Medicaid expansion discussion in the state must be by definition bipartisan. And that is indeed exactly what is happening in North Carolina in recent weeks as GOP State Senate leader Phil Berger, who in the past has repeatedly noted that he is opposed to expansion, is now indicating new openness to considering it along with other GOP leaders. A bipartisan committee is looking at the issue now and many observers think there may be a vote on the measure during North Carolina’s short session and before the November 2022 election. Recently, former Ohio GOP Governor John Kasich testified before the committee urging his fellow GOP members to consider the moral and human benefits of expansion while meeting their other goals for the state.

Mississippi – Appealing to “better angels”

While policymakers in Mississippi from the Governor to legislative leaders are still generally opposed to expanding Medicaid, Lieutenant Governor Delbert Hosemann has a different view. While avoiding talk of directly expanding Medicaid, Hosemann has been repeatedly bringing up the plight of the many working Mississippians who can’t get affordable coverage:

“What is expansion of Medicaid? That is a lazy question,” Hosemann retorted.
“What you need to be thinking about is how are we going to cover people who are working in Mississippi who have catastrophic illnesses? That is the real question.”
Hosemann told media members they need to focus on real life consequences instead of “some nomenclature that is three presidents ago.”

Those working hard in the state on making sure people have access to quality, affordable coverage welcome this change in focus. And even the Mississippi non-partisan state economist’s office has released a study showing the huge boost to the state’s economy with Medicaid expansion, outpacing even very large proposed tax cuts.

Wyoming – More debate but no movement

A Medicaid expansion bill passed in the Wyoming House last year, but subsequently failed in the state’s Senate. Last month, both the state’s House and the Senate tried to amend the 2023-2024 budget to expand Medicaid, given the substantial increase in federal funding from the American Rescue Plan. Despite a heartfelt plea by a state senator to expand health care coverage – based on his own past experiences being uninsured while having stage-three cancer – the proposed expansion failed. The Senate Rules Committee deemed it unconstitutional, as it was not an “ordinary expenditure” of the legislature.

Missouri – An expansion state (for now) with major delays in enrolling residents

Missouri voters chose to expand Medicaid in their state and expansion has been in effect for almost six months. Unlike other states that quickly enrolled nearly half their residents eligible for the new affordable coverage in the first few months, Missouri has lagged far behind, enrolling only about 25% of those eligible so far and putting many applications into an extended months-long waiting period for consideration – a delay that violates federal law. Meanwhile, an effort in the Missouri legislature is building to again put a measure concerning Medicaid expansion on the ballot. This measure, if passed, would effectively allow legislators to repeal voter-passed Medicaid expansion.

As these debates continue at the state and federal level, many residents of the twelve non-expansion states are still looking for affordable, quality health coverage.

To see where your state stands on Medicaid expansion and other health policy-related options, visit our State Data Hub.

Adam Searing is an Associate Professor at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.