Medicaid Expansion: Which States Benefit Most?

Medicaid Expansion: Which States Benefit Most?

The expansion of Medicaid under the Affordable Care Act (ACA) has significantly changed the health care landscape in the United States. By allowing states to broaden Medicaid eligibility to low-income adults, the federal government aimed to reduce the number of uninsured Americans and improve access to care. But not all states have chosen to expand Medicaid—and those that did are seeing different levels of impact.

What Is Medicaid Expansion?

Originally, Medicaid covered only specific groups like low-income families, pregnant women, and people with disabilities. The ACA allowed states to expand coverage to nearly all adults earning up to 138% of the federal poverty level (FPL), with the federal government covering most of the cost.

As of early 2025, 41 states and Washington D.C. have adopted Medicaid expansion, while a few holdouts—mainly in the South—have not.

States That Benefit the Most

Some states have seen major improvements in coverage, health outcomes, and economic savings. States that benefit most tend to share several traits:

1. Previously High Uninsured Rates

• States like Kentucky, Louisiana, and Arkansas saw sharp drops in uninsured rates after expansion. In Kentucky, the uninsured rate fell from 14% in 2013 to under 6% in just a few years.

2. Large Low-Income Populations

• States with large numbers of working poor, such as California and New York, have enrolled millions of new beneficiaries under Medicaid expansion, gaining both health and economic advantages.

3. Rural Populations and Hospital Strain

• In states like Montana and West Virginia, Medicaid expansion has provided critical funding to rural hospitals, helping prevent closures and sustain care in underserved areas.

Benefits Seen in Expansion States

• Increased coverage for low-income adults, especially among Black and Hispanic populations.

• Improved access to preventive services, chronic disease management, and mental health care.

• Lower uncompensated care costs for hospitals.

• Positive economic effects, including job creation in the health sector and budget savings through federal funding.

States That Have Not Expanded

As of 2025, several states—like Texas, Florida, Alabama, and Mississippi—have still not expanded Medicaid. These states continue to see higher uninsured rates, particularly among low-income working adults, and more financial strain on hospitals.

The Future of Medicaid Expansion

Political debates continue in non-expansion states, with voters in some places pushing for ballot measures. The federal government has also introduced incentives to encourage expansion, such as increased matching funds.

Conclusion

Medicaid expansion has proven to be a powerful tool for improving health care access and strengthening state health systems. While nearly every state that expanded Medicaid has seen major benefits, the impact has been especially strong in areas with previously high uninsured rates and vulnerable populations. As discussions continue, more states may still choose to adopt expansion and join the growing list of those reaping its rewards.