Medicaid Expansion
   HOME

TheInfoList



OR:

Under the public healthcare policy of the United States, some people have incomes too high to qualify in their state of residence for
Medicaid Medicaid is a government program in the United States that provides health insurance for adults and children with limited income and resources. The program is partially funded and primarily managed by U.S. state, state governments, which also h ...
, the public health insurance plan for those with limited resources, but too low to qualify for the
premium tax credit The premium tax credit (PTC) is a mechanism established by the Affordable Care Act (ACA) through which the United States federal government partially subsidizes the cost of private health insurance for certain lower- and middle-income individual ...
s that would subsidize the purchase of private health insurance. These people are described as falling into the Medicaid coverage gap. The 2010
Affordable Care Act The Affordable Care Act (ACA), formally known as the Patient Protection and Affordable Care Act (PPACA) and informally as Obamacare, is a landmark U.S. federal statute enacted by the 111th United States Congress and signed into law by Presid ...
(ACA) aimed to ensure
universal health care Universal health care (also called universal health coverage, universal coverage, or universal care) is a health care system in which all residents of a particular country or region are assured access to health care. It is generally organized a ...
through a number of mechanisms. It expanded Medicaid by raising the income threshold for eligibility to 138 percent of the
federal poverty line In the United States, poverty has both social and political implications. Based on Measuring poverty, poverty measures used by the Census Bureau (which exclude non-cash factors such as food stamps or medical care or public housing), America h ...
(FPL) among nonelderly adults. For those with income above the FPL who do not receive affordable health insurance from an employer, the ACA established
premium tax credit The premium tax credit (PTC) is a mechanism established by the Affordable Care Act (ACA) through which the United States federal government partially subsidizes the cost of private health insurance for certain lower- and middle-income individual ...
s that would subsidize the cost of buying private insurance through
health insurance marketplace In the United States, health insurance marketplaces, also called health exchanges, are organizations in each state through which people can purchase health insurance. People can purchase health insurance that complies with the Patient Protection ...
s. State participation in Medicaid is theoretically voluntary, although all states have participated since 1982. The program is funded jointly by the state and Federal governments, though the Federal government pays for the vast majority of the ACA expansion; the framers of the ACA assumed that all states would continue to participate in the newly expanded Medicaid, which is why subsidies for private insurance are only available for those with incomes above the FPL. Nevertheless, opponents of the ACA asserted that the federal government's conditioning of continued funding for Medicaid on adoption of expansion was unconstitutionally coercive. The
Supreme Court In most legal jurisdictions, a supreme court, also known as a court of last resort, apex court, high (or final) court of appeal, and court of final appeal, is the highest court within the hierarchy of courts. Broadly speaking, the decisions of ...
held in '' National Federation of Independent Business v. Sebelius'' that adoption of Medicaid expansion by states was effectively optional, and that states could continue with their preexisting Medicaid requirements without risk of defunding. In many of the states that chose to reject the expansion, only those making significantly below the FPL qualify for Medicaid; this has led to a "gap" in coverage for residents of those states with incomes that are too low to qualify for private insurance subsidies and too high to qualify for the non-expanded Medicaid. , 40 states and the District of Columbia have adopted Medicaid expansion, leaving 10 states that have not. An estimated 1.9 million Americans in those 10 states are within the Medicaid coverage gap according to the
Kaiser Family Foundation KFF, which was formerly known as The Kaiser Family Foundation or The Henry J. Kaiser Family Foundation, is an American non-profit organization, non-profit organization, headquartered in San Francisco, San Francisco, California. It prefers KFF, w ...
. Approximately 97 percent of this cohort lives in the Southern U.S., with a majority living in
Texas Texas ( , ; or ) is the most populous U.S. state, state in the South Central United States, South Central region of the United States. It borders Louisiana to the east, Arkansas to the northeast, Oklahoma to the north, New Mexico to the we ...
and
Florida Florida ( ; ) is a U.S. state, state in the Southeastern United States, Southeastern region of the United States. It borders the Gulf of Mexico to the west, Alabama to the northwest, Georgia (U.S. state), Georgia to the north, the Atlantic ...
; Texas has the largest population of people in the cohort, accounting for 41 percent of people in the coverage gap.


Population characteristics

As initially passed, the ACA was designed to provide
universal health care Universal health care (also called universal health coverage, universal coverage, or universal care) is a health care system in which all residents of a particular country or region are assured access to health care. It is generally organized a ...
in the U.S.: those with employer-sponsored health insurance would keep their plans, those with middle-income and lacking employer-sponsored health insurance could purchase subsidized insurance via newly established
health insurance marketplace In the United States, health insurance marketplaces, also called health exchanges, are organizations in each state through which people can purchase health insurance. People can purchase health insurance that complies with the Patient Protection ...
s, and those with low-income would be covered by the expansion of Medicaid. However, the
U.S. Supreme Court The Supreme Court of the United States (SCOTUS) is the highest court in the federal judiciary of the United States. It has ultimate appellate jurisdiction over all U.S. federal court cases, and over state court cases that turn on question ...
ruling in '' National Federation of Independent Business v. Sebelius'' (2012) rendered state adoption of Medicaid expansion optional. Governors in several Republican-leaning states announced that they would not expand Medicaid in response, leading to a gap in insurance coverage. The Medicaid coverage gap includes nonelderly people with incomes that are below the
federal poverty line In the United States, poverty has both social and political implications. Based on Measuring poverty, poverty measures used by the Census Bureau (which exclude non-cash factors such as food stamps or medical care or public housing), America h ...
(FPL), making them ineligible for subsidized marketplace insurance under the
Affordable Care Act The Affordable Care Act (ACA), formally known as the Patient Protection and Affordable Care Act (PPACA) and informally as Obamacare, is a landmark U.S. federal statute enacted by the 111th United States Congress and signed into law by Presid ...
(ACA), but have incomes higher than their state's limit for
Medicaid Medicaid is a government program in the United States that provides health insurance for adults and children with limited income and resources. The program is partially funded and primarily managed by U.S. state, state governments, which also h ...
eligibility as their state has not adopted Medicaid expansion as prescribed by the ACA. The gap also includes childless adults who are ineligible for Medicaid regardless of income in these states (with the exception of
Wisconsin Wisconsin ( ) is a U.S. state, state in the Great Lakes region, Great Lakes region of the Upper Midwest of the United States. It borders Minnesota to the west, Iowa to the southwest, Illinois to the south, Lake Michigan to the east, Michig ...
, which permits Medicaid coverage via waiver). , an estimated 1.9 million people are in the Medicaid coverage gap, residing in
Alabama Alabama ( ) is a U.S. state, state in the Southeastern United States, Southeastern and Deep South, Deep Southern regions of the United States. It borders Tennessee to the north, Georgia (U.S. state), Georgia to the east, Florida and the Gu ...
,
Florida Florida ( ; ) is a U.S. state, state in the Southeastern United States, Southeastern region of the United States. It borders the Gulf of Mexico to the west, Alabama to the northwest, Georgia (U.S. state), Georgia to the north, the Atlantic ...
,
Georgia Georgia most commonly refers to: * Georgia (country), a country in the South Caucasus * Georgia (U.S. state), a state in the southeastern United States Georgia may also refer to: People and fictional characters * Georgia (name), a list of pe ...
,
Kansas Kansas ( ) is a landlocked U.S. state, state in the Midwestern United States, Midwestern region of the United States. It borders Nebraska to the north; Missouri to the east; Oklahoma to the south; and Colorado to the west. Kansas is named a ...
,
Mississippi Mississippi ( ) is a U.S. state, state in the Southeastern United States, Southeastern and Deep South regions of the United States. It borders Tennessee to the north, Alabama to the east, the Gulf of Mexico to the south, Louisiana to the s ...
,
South Carolina South Carolina ( ) is a U.S. state, state in the Southeastern United States, Southeastern region of the United States. It borders North Carolina to the north and northeast, the Atlantic Ocean to the southeast, and Georgia (U.S. state), Georg ...
,
Tennessee Tennessee (, ), officially the State of Tennessee, is a landlocked U.S. state, state in the Southeastern United States, Southeastern region of the United States. It borders Kentucky to the north, Virginia to the northeast, North Carolina t ...
,
Texas Texas ( , ; or ) is the most populous U.S. state, state in the South Central United States, South Central region of the United States. It borders Louisiana to the east, Arkansas to the northeast, Oklahoma to the north, New Mexico to the we ...
, Wisconsin, and
Wyoming Wyoming ( ) is a landlocked U.S. state, state in the Mountain states, Mountain West subregion of the Western United States, Western United States. It borders Montana to the north and northwest, South Dakota and Nebraska to the east, Idaho t ...
. Out of the cohort, 97 percent live in the
Southern United States The Southern United States (sometimes Dixie, also referred to as the Southern States, the American South, the Southland, Dixieland, or simply the South) is List of regions of the United States, census regions defined by the United States Cens ...
where most of the non-expansion states are located, with Texas, Florida, and Georgia accounting for nearly three-quarters of the Medicaid coverage gap. Childless adults account for 76 percent of the coverage gap, and
people of color The term "person of color" (: people of color or persons of color; abbreviated POC) is used to describe any person who is not considered "white". In its current meaning, the term originated in, and is associated with, the United States. From th ...
account for around 61 percent of the cohort. Within the ten states that have not opted for Medicaid expansion, the median income limit for eligibility in the traditional Medicaid program is 38 percent of the FPL. The uninsured rate within the non-expansion states was 15.4 percent compared to 8.1 percent in expansion states.


Medicaid expansion


Affordable Care Act provision

Prior to passage of the ACA,
Medicaid Medicaid is a government program in the United States that provides health insurance for adults and children with limited income and resources. The program is partially funded and primarily managed by U.S. state, state governments, which also h ...
did not extend general eligibility to low-income adults without child dependents, though the federal government could authorize waivers for states to expand medicaid coverage; by 2012, eight states provided full Medicaid benefits to this group. The Medicaid statute also permitted states to cover some cohorts (termed "optional eligibility groups") without a permit. However, some states set stringent income eligibility thresholds well below the federal poverty level (FPL) for caretakers and parents of minors. In line with its previous efforts to curtail the expansion of the State Children’s Health Insurance Program (SCHIP), the Bush administration imposed additional restrictions on states attempting to raise the income cap for Medicaid eligibility in 2008.
Healthcare reform Health care reform is for the most part governmental policy that affects health care delivery in a given place. Health care reform typically attempts to: * Broaden the population that receives health care coverage through either public sector insu ...
was a key issue in campaigns for the
2008 United States presidential election Presidential elections were held in the United States on November 4, 2008. The Democratic ticket of Barack Obama, the junior senator from Illinois, and Joe Biden, the senior senator from Delaware, defeated the Republican ticket of John Mc ...
. A poll of delegates conducted by the ''
New York Times ''The New York Times'' (''NYT'') is an American daily newspaper based in New York City. ''The New York Times'' covers domestic, national, and international news, and publishes opinion pieces, investigative reports, and reviews. As one of ...
'' and
CBS News CBS News is the news division of the American television and radio broadcaster CBS. It is headquartered in New York City. CBS News television programs include ''CBS Evening News'', ''CBS Mornings'', news magazine programs ''CBS News Sunday Morn ...
found that 94 percent of Democratic delegates viewed expanding healthcare coverage to all Americans as more important than lowering taxes, compared to 7 percent for Republican delegates. The ACA was signed into law in March 2010 by President
Barack Obama Barack Hussein Obama II (born August 4, 1961) is an American politician who was the 44th president of the United States from 2009 to 2017. A member of the Democratic Party, he was the first African American president in American history. O ...
after passing with narrow majorities in the
House A house is a single-unit residential building. It may range in complexity from a rudimentary hut to a complex structure of wood, masonry, concrete or other material, outfitted with plumbing, electrical, and heating, ventilation, and air c ...
and
Senate A senate is a deliberative assembly, often the upper house or chamber of a bicameral legislature. The name comes from the ancient Roman Senate (Latin: ''Senatus''), so-called as an assembly of the senior (Latin: ''senex'' meaning "the el ...
on nearly party lines. Softening the eligibility requirements for Medicaid was a central goal of the ACA, forming a two-pronged policy along with subsidized
private insurance Private or privates may refer to: Music * "In Private", by Dusty Springfield from the 1990 album ''Reputation'' * Private (band), a Denmark-based band * "Private" (Ryōko Hirosue song), from the 1999 album ''Private'', written and also recorded ...
via
health insurance marketplace In the United States, health insurance marketplaces, also called health exchanges, are organizations in each state through which people can purchase health insurance. People can purchase health insurance that complies with the Patient Protection ...
s to expand health insurance coverage in the U.S. The Medicaid expansion provision of the ACA allowed states to lower the income requirements for Medicaid eligibility, extending eligibility to non-pregnant adults under the age of 65 and not entitled to Medicare with incomes of up to 138 percent of the federal poverty level. Within this cohort were three primary categories of adults: adults without dependent children, parents with dependent children, and adults with disabilities. The ACA sought to eliminate categorical criteria barring these groups from Medicaid eligibility and standardize requirements across states. The expansion provision also stipulated that the federal government would cover an enhanced share of the additional Medicaid expenditure incurred by states as a result of Medicaid expansion. The expansion was to be enacted 2014, with the federal government funding 100 percent of states' costs through 2016 and then gradually declining its share stepwise to 90 percent in 2020 and onwards. The ACA granted federal support to states classified as "expansion states" based on the following requirements: The
Congressional Budget Office The Congressional Budget Office (CBO) is a List of United States federal agencies, federal agency within the United States Congress, legislative branch of the United States government that provides budget and economic information to Congress. I ...
(CBO) estimated that Medicaid expansion under ACA as originally passed would cover 17 million uninsured Americans by 2022. The newly covered adult population in participating states were required to receive health coverage under an Alternative Benefit Plan (ABP) comparable or equivalent to either the state's traditional Medicaid package or a benchmark plan chosen by the state, with mandatory coverage in ten categories of health benefits deemed essential by the ACA. Those deemed medically frail would be given the option of choosing either the ABP or the traditional benefit package. The ABP would also cover screening and diagnostic and treatment services for enrollees younger than 21 years. While Medicaid expansion was to come into force in 2014, the ACA also provided states the option to expand Medicaid early and receive
matching funds Matching funds are funds that are set to be paid in proportion to funds available from other sources. Matching fund payments usually arise in situations of charity or public good. The terms cost sharing, in-kind, and matching can be used inter ...
from the federal government in raising the income cap for Medicaid as prescribed by ACA. States could also receive matching funds by expanding Medicaid early through other mechanisms and obtaining a Section 1115 waiver.


''National Federation of Independent Business v. Sebelius'' (2012)

Although Medicaid expansion under ACA was a ''de jure'' voluntary initiative for states, it was intended to be implemented nationally. Opponents of the legislation described the conditioning of the increased funding for Medicaid on states opting into expansion as unconstitutionally coercive, making Medicaid expansion effectively mandatory. The federal government typically covered only 50–83 percent of Medicaid costs prior to ACA, with its share determined by the state's average per capita income. The elevated share for Medicaid expansion implied over $500 billion in additional federal funding between 2014 and 2020. In ''National Federation of Independent Business'', the
plaintiff A plaintiff ( Π in legal shorthand) is the party who initiates a lawsuit (also known as an ''action'') before a court. By doing so, the plaintiff seeks a legal remedy. If this search is successful, the court will issue judgment in favor of the ...
s challenged the
constitutionality In constitutional law, constitutionality is said to be the condition of acting in accordance with an applicable constitution; "Webster On Line" the status of a law, a procedure, or an act's accordance with the laws or set forth in the applic ...
of the ACA and contended that the Medicaid expansion provision was coercive. The U.S. District Court for the Northern District of Florida ruled in favor of the federal government on Medicaid expansion, and this ruling was upheld 2–1 in the U.S. Court of Appeals for the Eleventh Circuit. While the
Supreme Court In most legal jurisdictions, a supreme court, also known as a court of last resort, apex court, high (or final) court of appeal, and court of final appeal, is the highest court within the hierarchy of courts. Broadly speaking, the decisions of ...
largely upheld the constitutionality of the ACA, the court ruled in a 7–2 decision that the Medicaid expansion provision was unconstitutionally coercive. The court established that the federal government could not condition funding for a preexisting program (i.e. Medicaid) on state participation in what the court classified as a new program (i.e. Medicaid expansion). However, the court also ruled 5–4 that Medicaid expansion without the federal threat of defunding Medicaid in non-compliant states fell within the powers afforded by the
Spending Clause The Taxing and Spending Clause (which contains provisions known as the General Welfare Clause and the Uniformity Clause), Article I, Section 8, Clause 1 of the United States Constitution, grants the federal government of the United States its ...
to
Congress A congress is a formal meeting of the representatives of different countries, constituent states, organizations, trade unions, political parties, or other groups. The term originated in Late Middle English to denote an encounter (meeting of ...
. Adoption of Medicaid expansion by individual states was effectively optional as a result of ''National Federation of Independent Business''. States opting out of Medicaid expansion could continue with their preexisting Medicaid requirements without the risk of federal defunding while states accepting the enhanced federal funding would be required to participate in Medicaid expansion. In July 2012, the CBO revised its projection of Americans covered by Medicaid expansion by 2022 to 11 million as a result of the ruling. When the ACA fully came into effect in January 2014, 24 states and the
District of Columbia Washington, D.C., formally the District of Columbia and commonly known as Washington or D.C., is the capital city and Federal district of the United States, federal district of the United States. The city is on the Potomac River, across from ...
adopted Medicaid expansion. Most states implemented Medicaid expansion via expansion of their Medicaid programs while some states did so by other means such as the use of
health savings account A health savings account (HSA) is a tax advantage, tax-advantaged medical savings account available to taxpayers in the United States who are enrolled in a high-deductible health plan (HDHP). The funds contributed to an account are not subject t ...
s. The incongruous adoption of Medicaid expansion was a result of several factors, including partisanship and pressure from
private insurance Private or privates may refer to: Music * "In Private", by Dusty Springfield from the 1990 album ''Reputation'' * Private (band), a Denmark-based band * "Private" (Ryōko Hirosue song), from the 1999 album ''Private'', written and also recorded ...
stakeholders. Primarily Republican resistance to Medicaid expansion prevented adoption of the provision in other states, with opponents characterizing expansion as an overreach of the federal government into a
free market In economics, a free market is an economic market (economics), system in which the prices of goods and services are determined by supply and demand expressed by sellers and buyers. Such markets, as modeled, operate without the intervention of ...
space and arguing that expansion would raise healthcare costs and lower coverage quality. The American Rescue Plan Act of 2021, which passed in March 2021, compelled the federal government to cover an additional 5 percent of state expenditure incurred by Medicaid expansion atop the 90 percent stipulated by ACA to incentivize the then-12 non-expansion states to adopt Medicaid expansion, in addition to
Missouri Missouri (''see #Etymology and pronunciation, pronunciation'') is a U.S. state, state in the Midwestern United States, Midwestern region of the United States. Ranking List of U.S. states and territories by area, 21st in land area, it border ...
and
Oklahoma Oklahoma ( ; Choctaw language, Choctaw: , ) is a landlocked U.S. state, state in the South Central United States, South Central region of the United States. It borders Texas to the south and west, Kansas to the north, Missouri to the northea ...
which had adopted but not implemented expansion at the time. , 40 states and the District of Columbia have adopted Medicaid expansion while 10 have not.


States adopting Medicaid expansion after ACA enactment


Maine

On November 16, 2012, Governor of Maine Paul LePage declared that he would not be implementing Medicaid expansion in Maine; at the time, Medicaid expansion in his state would expand health coverage to 37,000 people. Proponents for expansion in Maine argued that it would bolster rural hospitals and create new jobs; opponents cited previous problems with the state budget following earlier expansions of Medicaid in the state prior to the ACA LePage remained a stalwart objector of Medicaid expansion thereafter, asserting that expansion would divert funds from other state programs and often summarizing his stance as "free is expensive to somebody." He vetoed five Medicaid expansion bills passed by the Maine legislature between 2013 and 2017. On October 13, 2016, Maine Equal Justice Partners, a progressive advocacy group, announced that it would begin canvassing for signatures to hold a referendum on Medicaid expansion in the state. Maine Equal Justice Partners stated that over 65,000 signatures were collected on Election Day in 2016, enough to place Medicaid expansion on the ballot in a subsequent election. Expansion of Medicaid was introduced to the ballot for the November 2017 election as Question 2. Around $2 million was spent on campaigning in support of the ballot measure compared to less than $300,000 for opposition to the measure. Question 2 passed with 59 percent of the vote, making Maine the first state to approve Medicaid expansion by ballot measure. Support was strongest in southern and coastal Maine. At the time of passage, the expanded eligibility for Medicaid would encompass 70,000 more adults. Passage of the measure compelled the state to enact expansion legislation 30 days after finalization of the election results and submit its expansion plan to the
United States Department of Health and Human Services The United States Department of Health and Human Services (HHS) is a cabinet-level executive branch department of the US federal government created to protect the health of the US people and providing essential human services. Its motto is ...
(HHS) within 90 days of legislative enactment. Despite the successful ballot initiative, LePage indicated that Medicaid expansion would not be implemented until the state legislature was able to fund Maine's share of the expansion without increasing taxes, using the state's rainy day fund, or curtailing services for the elderly and disabled. Sara Gideon, the Speaker of the Maine House of Representatives, responded by stating that "Any attempts to illegally delay or subvert xpansion legislation would "be fought with every recourse at our disposal." The Maine legislature failed to overturn LePage's veto of the accompanying legislation in July 2018. Maine Equal Justice Partners sued to force the LePage administration to accept federal funding for Medicaid expansion, resulting in an order from the Kennebec County Superior Court compelling LePage to submit an expansion plan to the HHS. However, LePage continued to defy Medicaid expansion, stating that he would “go to jail" before implementing Medicaid expansion without prior appropriation of state funding; his administration appealed the court order to the
Maine Supreme Judicial Court The Maine Supreme Judicial Court is the highest court in the state of Maine's judicial system. It is composed of seven justices, who are appointed by the governor and confirmed by the Maine Senate. Between 1820 and 1839, justices served lifetime ...
, which dismissed the appeal in August 2018. The administration filed the requisite documents for Medicaid expansion to the federal government the following month, but LePage concurrently wrote a letter encouraging CMS to reject expansion in Maine. Maine Equal Justice Partners subsequently filed suit against the administration in the Maine Business and Consumer Court, seeking to rescind portions of Maine's Medicaid expansion application that asked the federal government to deny expansion.
Janet Mills Janet Trafton Mills (born December 30, 1947) is an American politician and lawyer serving since 2019 as the 75th governor of Maine. She previously served as Maine Attorney General. A member of the Democratic Party, Mills was first elected a ...
won the 2018 Maine gubernatorial election; Mills had campaigned on Medicaid expansion and stated the expansion would be implemented immediately at the start of her governorship following LePage's departure. The outgoing administration continued to stall expansion of Medicaid; following another legal challenge, the Maine Superior Court set February 1, 2019, as the start date for enrollments into expanded Medicaid. Shortly after taking office, Mills signed an executive order on January 3, 2019, directing the expansion of Medicaid and opening enrollments for the program. Medicaid expansion was implemented in Maine on January 10, 2019, with coverage provided to those eligible retroactive to July 2018.


Oklahoma

Following the Supreme Court's ruling in ''National Federation of Independent Business'' in 2012, Oklahoma Governor
Mary Fallin Mary Fallin (; née Copeland; born December 9, 1954) is an American politician who served as the 27th governor of Oklahoma from 2011 to 2019. A member of the Republican Party (United States), Republican Party, she was elected in 2010 Oklahoma gub ...
stated she was skeptical of Medicaid expansion in Oklahoma but would assess the possibility. Fallin later put off the decision until after the 2012 election.
Tom Coburn Thomas Allen Coburn (March 14, 1948 – March 28, 2020) was an American politician and medical doctor, physician who served as a United States senator from Oklahoma from 2005 to 2015. A Republican Party (United States), Republican, Coburn ...
, the junior U.S. senator from Oklahoma, wrote a letter to Fallin in October 2012 warning against expanding the state's Medicaid program. On November 19, 2012, Fallin announced that the state would not be moving forward with Medicaid expansion, citing high costs and the resulting need for budget cuts to other government programs. In 2016, Fallin and Nico Gomez, the executive director of the Oklahoma Health Care Authority (OHCA), proposed creating a subsidized private option for the Medicaid coverage gap administered through the OHCA's Insure Oklahoma program, mitigating expansion of Medicaid. Termed the "Medicaid Rebalancing Act of 2020", the plan was to be partly federally funded. However, the proposal lost momentum in the
Oklahoma Senate The Oklahoma Senate is the upper house of the two houses of the Legislature of Oklahoma, the other being the Oklahoma House of Representatives. The total number of senators is set at 48 by the Oklahoma Constitution. Gomez, who championed the proposal, resigned in August 2016. In December 2018, in the wake of the 2018 midterm elections, Democrats in the
Oklahoma House of Representatives The Oklahoma House of Representatives is the lower house of the legislature of the U.S. state of Oklahoma. Its members introduce and vote on bills and resolutions, provide legislative oversight for state agencies, and help to craft the state's ...
announced that they would legislatively push for Medicaid expansion. A
grassroots A grassroots movement is one that uses the people in a given district, region or community as the basis for a political or continent movement. Grassroots movements and organizations use collective action from volunteers at the local level to imp ...
effort to put forth a Medicaid expansion ballot initiative began in April 2019 as opposition from Republican legislators and newly elected governor
Kevin Stitt John Kevin Stitt (born December 28, 1972) is an American businessman and politician serving as the 28th governor of Oklahoma since 2019. A member of the Republican Party, he was elected in 2018, defeating Democrat and former state Attorney Ge ...
made expansion via the legislature unlikely. The conservative think tank Oklahoma Council of Public Affairs challenged the proposal in the
Oklahoma Supreme Court The Supreme Court of Oklahoma is a court of appeal for non-criminal cases, one of the two highest judicial bodies in the U.S. state of Oklahoma, and leads the judiciary of Oklahoma, the judicial branch of the government of Oklahoma.
, arguing that the language of the associated petition was inaccurate and that the proposed policy was unconstitutional; the court ruled in June 2019 that the petition could continue collecting signatures. Canvassing to qualify the initiative on the ballot began on July 31, 2019. The ballot initiative campaign submitted 313,677 signatures to the Oklahoma Secretary of State in October 2019, exceeding the 178,000 needed to place the measure on the ballot and setting a state record for signatures collected for an initiative petition. As canvassing for the ballot initiative was ongoing, a bipartisan legislative
working group A working group is a group of experts working together to achieve specified goals. Such groups are domain-specific and focus on discussion or activity around a specific subject area. The term can sometimes refer to an interdisciplinary collab ...
intended to address Medicaid expansion and healthcare coverage began convening and regularly meeting. Both Stitt and the working group sought to devise alternatives to the Medicaid expansion outlined by the initiative. Stitt unveiled his proposal, dubbed SoonerCare 2.0, in March 2020; the plan involved expansion of the state's Medicaid program including work requirements and tiered monthly premiums and copays. His plan was to serve as the state's use of CMS's Healthy Adult Opportunity program with an anticipated rollout in July 2020. The ballot initiative appeared on the ballot for the 2020 primaries as State Question 802, with support from several health organizations and Native American tribes in the state. The measure passed by less than a percentage-point margin, compelling the state to implement Medicaid expansion by July 1, 2021. Stitt withdrew his healthcare proposal following passage of the initiative.


South Dakota

The Republican-controlled
South Dakota Legislature The South Dakota Legislature is the legislative branch of the government of South Dakota. It is a bicameral legislative body, consisting of the South Dakota Senate, which has 35 members, and the South Dakota House of Representatives, which has 7 ...
long opposed Medicaid expansion. Proponents of Medicaid expansion in the state emphasized the benefits to healthcare access and rural hospitals, particularly in the aftermath of the COVID-19 epidemic, while critics argued that expanding Medicaid would be fiscally irresponsible, lead to tax increases, and discourage able-bodied adults from seeking work. In October 2014, telephone poll conducted by Mason-Dixon Polling & Strategy of 800 registered voters in the state found that respondents supported Medicaid expansion as outlined in ACA by a 45–37 percent margin, with an additional 18 percent of respondents undecided. In 2015, South Dakota Governor Dennis Daugaard proposed extending Medicaid coverage to 55,000 residents and raising health spending for Native Americans. However, a deal could not be reached between the state and the
U.S. Department of Health and Human Services The United States Department of Health and Human Services (HHS) is a cabinet-level executive branch department of the US federal government created to protect the health of the US people and providing essential human services. Its motto is "Im ...
before the end of then-President Obama's term. A coalition of advocacy groups, including Dakotans for Health, began canvassing for signatures in 2021 to place a constitutional amendment to expand Medicaid on the ballot for the 2022 election. The state legislature drafted a resolution that would put to vote a constitutional amendment requiring subsequent ballot measures to garner 60 percent of the vote if the measure created new taxes or required more than $10 million in state appropriations within the first five years of enactment. In March 2021, the South Dakota Senate voted to expedite voting on the measure, moving it from the 2022 general election to the 2022 
primaries Primary elections or primaries are elections held to determine which candidates will run in an upcoming general election. In a partisan primary, a political party selects a candidate. Depending on the state and/or party, there may be an "open pri ...
. The associated amendment was added to the ballot for the 2022 primaries as Constitutional Amendment C. Supporters of Medicaid expansion viewed passage of Amendment C as an attempt to prevent Medicaid expansion from passing via
ballot initiative A popular initiative (also citizens' initiative) is a form of direct democracy by which a petition meeting certain hurdles can force a legal procedure on a proposition. In direct initiative, the proposition is put directly to a plebiscite o ...
; Dakotans for Health unsuccessfully challenged the resolution in the
South Dakota Supreme Court The South Dakota Supreme Court is the highest court in the state of South Dakota. It is composed of a chief justice and four associate justices appointed by the governor. One justice is selected from each of five geographic appointment districts ...
in May 2021. Medicaid expansion was placed on the 2022 general election ballot as Constitutional Amendment D after garnering 38,244 signatures. Concurrently, Republican State Senator Wayne Steinhauer introduced a proposal to the South Dakota Legislature to expand Medicaid, arguing that the wording of Amendment D was not desirable and proposing withdrawal of the ballot measure if his bill was passed. His Republican colleagues argued that expanding the program would expand the government and pull funding away from public schools. The Republican-led
South Dakota Senate The South Dakota Senate is the upper house of the South Dakota Legislature. It consists of 35 members, one representing each legislative district. It meets at the South Dakota State Capitol in Pierre. Composition :''99th Legislature (2025)' ...
voted against the proposal by a 12–13 vote on February 15, 2022. Amendment C later failed by a 67.4–32.6 percentage point margin in the 2022 primary election, ensuring that Amendment D could pass by
majority vote A majority is more than half of a total; however, the term is commonly used with other meanings, as explained in the "#Related terms, Related terms" section below. It is a subset of a Set (mathematics), set consisting of more than half of the se ...
. Governor
Kristi Noem Kristi Lynn Arnold Noem ( ; née Arnold; born November 30, 1971) is an American politician serving as the 8th United States secretary of homeland security since 2025. A member of the Republican Party, she served from 2019 to 2025 as the 33rd ...
opposed Medicaid expansion, but stated in a September 2022 debate for the 2022 gubernatorial election that Medicaid expansion would be implemented if passed by ballot initiative, provided that it was "written constitutionally." Amendment D passed by a 12.4-percentage point margin, with 56.2 percent of voters supporting the measure. The passage of Constitutional Amendment D set into motion the expansion of Medicaid to 42,500 new adult and nonelderly South Dakotans by July 1, 2023. People within the Medicaid coverage gap are expected to account for approximately a third of the newly eligible population. The state Department of Social Services estimated that 52,000 people would enroll in the expanded program.


Utah

Medicaid expansion in
Utah Utah is a landlocked state in the Mountain states, Mountain West subregion of the Western United States. It is one of the Four Corners states, sharing a border with Arizona, Colorado, and New Mexico. It also borders Wyoming to the northea ...
remained an undecided issue in the state government in the aftermath of ''NFIB v. Sebelius''. The Republican-controlled
state legislature A state legislature is a Legislature, legislative branch or body of a State (country subdivision), political subdivision in a Federalism, federal system. Two federations literally use the term "state legislature": * The legislative branches of ...
was staunchly opposed to Medicaid expansion due to its costs and distrust of the federal government. While Governor
Gary Herbert Gary Richard Herbert (born May 7, 1947) is an American politician who served as the 17th governor of Utah from 2009 to 2021. A member of the Republican Party, he chaired the National Governors Association during the 2015–2016 cycle. Herbert w ...
elected to wait for an independent analysis of Medicaid expansion to make a decision, Republican lawmakers sought to pass a bill prohibiting Medicaid expansion without approval from the state legislature; the
Utah House of Representatives The Utah House of Representatives is the lower house of the Utah State Legislature, the state legislature of the U.S. state of Utah. The House is composed of 75 representatives elected from single member constituent districts. Each district cont ...
approved the bill by a 46–27 vote on March 11, 2013. Medicaid expansion in Utah took effect on January 1, 2020.


See also

*
Medicaid Medicaid is a government program in the United States that provides health insurance for adults and children with limited income and resources. The program is partially funded and primarily managed by U.S. state, state governments, which also h ...
* Medicaid estate recovery *
Patient Protection and Affordable Care Act A patient is any recipient of health care services that are performed by healthcare professionals. The patient is most often ill or injured and in need of treatment by a physician, nurse, optometrist, dentist, veterinarian, or other health ...


Notes


References

{{Reflist Affordable Care Act Medicare and Medicaid (United States) Federal assistance in the United States