Six States Are Considering Medicaid Expansion Bills So Far This Year

In an effort to increase health insurance coverage, the Affordable Care Act (ACA) included provisions mandating states to expand their Medicaid programs for residents earning up to 138 percent of the federal poverty level (FPL). However, the U.S. Supreme Court ruled in 2012 (National Federation of Independent Business v. Sebelius) that the ACA could not force states to expand their Medicaid programs, leaving the decision up to the states. 

Medicaid expansion took effect in 2014 with 25 states and Washington, D.C., initially adopting expansion as directed under the ACA. Over the past decade, that number has gradually grown as additional states have adopted expansion through legislative and executive action, alternative models approved by the federal government via 1115 waivers (authorized under Section 1115 of the Social Security Act), and ballot measures. Today, 40 states and Washington, D.C., have expanded Medicaid under the ACA. 

Medicaid Expansion Ballot Measures

In recent years, supporters of expansion have relied on ballot initiatives to get expansion passed. This has proven to be an effective strategy, with voters in 7 states approving Medicaid expansion measures. Maine was the first state to expand Medicaid via ballot measure in 2017 and South Dakota was the most recent in 2022. However, the ballot measure process is reaching its limit as Florida and Wyoming are the only remaining non-expansion states with a ballot initiative process. Supporters of expansion in both states face barriers to placing the issue on the ballot. In Wyoming, ballot initiatives cannot make appropriations, which would be necessary for Medicaid expansion. In Florida, supporters of expansion abandoned an initiative during the 2020 election cycle after the legislature made changes to the signature-gathering process. Supporters of expansion have indicated that they are trying to get the issue before Florida voters in 2026.  

Legislative Action on Medicaid Expansion

Mississippi, Wisconsin, Kansas, Tennessee, Georgia, and South Carolina have introduced or carried over Medicaid expansion bills for the 2024 legislative session so far. Passage of such legislation faces an uphill battle as all of the remaining non-expansion states have Republican-controlled legislatures opposed to expansion. However, in 2023 North Carolina became the first state since Virginia in 2018 to enact Medicaid expansion through the legislative process (NC HB 76) after years of negotiations between the Republican-controlled legislature and Democratic Governor Roy Cooper. 

Kansas and Wisconsin are the only remaining non-expansion states without a Republican trifecta. In Kansas, Democratic Governor Laura Kelly has marked Medicaid expansion as a priority for 2024. Gov. Kelly urged lawmakers to consider her proposal, the Cutting Healthcare Costs for All Kansans Act (KS HB 2556/KS SB 355), during her 2024 State of the State address and highlighted key aspects of the proposal that might appeal to Republicans, such as how the proposal is revenue-neutral and includes work requirements for eligibility. In Wisconsin, Democratic Governor Tony Evers, included Medicaid expansion in his FY 2023-2025 budget proposal last year, but it was ultimately amended out of the enacted budget.  

Tracking State Health Care Legislation 

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