Medicaid Expansion Status

The Affordable Care Act's Medicaid expansion extended coverage to adults earning up to 138% of the federal poverty level (~$20,800/year for an individual in 2026) — but the Supreme Court's 2012 NFIB v. Sebelius decision made expansion optional for states. Today, 40 states plus DC have expanded Medicaid; 10 states have not: Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming. This creates a "coverage gap" in non-expansion states affecting approximately 2 million people: adults who earn too much for traditional Medicaid (which in non-expansion states often has very low eligibility limits for non-pregnant adults without children) but too little to qualify for ACA Marketplace premium subsidies, which start at 100% FPL. Texas alone has about 1 million people in the coverage gap. The federal government pays 90% of the cost of expansion (vs. the traditional 50-77% federal share), making expansion fiscally attractive for states — the remaining holdout states are primarily resisting on philosophical grounds about expanding government health programs. The 2025 Republican reconciliation legislation is proposing per capita caps or block grants that would significantly change Medicaid's financial structure, representing the most significant threat to Medicaid expansion since 2012.

Current Law (2026)

The ACA expanded Medicaid eligibility to adults with income up to 138% FPL. The Supreme Court made expansion optional for states (NFIB v. Sebelius, 2012).

Status	States
Expanded (40 + DC)	All other states
Not expanded (10)	AL, FL, GA, KS, MS, SC, TN, TX, WI, WY
Coverage gap (non-expansion only)	Adults with income too high for traditional Medicaid, too low for ACA subsidies (0-100% FPL)
Gap population size	~2 million people

Legal Authority

42 U.S.C. § 1396a — State plans for medical assistance (mandatory eligibility groups, expansion group requirements)
42 U.S.C. § 1396d(y) — Increased FMAP for expansion population (90% federal match)
ACA Section 2001 — Medicaid expansion to 138% FPL (made optional by NFIB v. Sebelius, 2012)

How It Works

Under 42 U.S.C. § 1396d(y), the federal government pays 90% of the cost of covering Medicaid expansion enrollees — a permanently enhanced match rate, regardless of when a state expands. The traditional federal Medicaid match is 50–77% depending on state per-capita income, so expansion provides substantially higher federal support than standard Medicaid. Non-expansion states have declined tens of billions of dollars annually in federal funds — a calculation that has gradually moved late-expanding states: South Dakota (ballot initiative, 2022; effective July 2023) and North Carolina (legislative vote, December 2023) are the most recent additions.

The coverage gap in non-expansion states results from the interaction of two federal systems: Medicaid in these states typically covers only children, pregnant women, and certain disabled adults — childless non-disabled adults have essentially no eligibility regardless of income. ACA marketplace subsidies start at 100% FPL (~$15,060 individual in 2026), assuming Congress expected everyone below that threshold to receive Medicaid. Adults earning below 100% FPL in non-expansion states fall through: ineligible for traditional Medicaid, ineligible for marketplace subsidies. The gap affects approximately 2 million people, concentrated in Texas (~1 million), Florida, and Georgia.

Some non-expansion states have used Section 1115 waivers to cover some adults with more restrictive conditions — including work requirements, premiums, or coverage limits. Wisconsin covers adults to 100% FPL; Georgia's "Pathways" program requires documented community engagement hours. These partial programs don't close the coverage gap but extend some coverage to some populations. Children in non-expansion states may still qualify for coverage through CHIP, which operates independently of the expansion status.

How It Affects You

If you live in a non-expansion state (TX, FL, GA, SC, and others): The coverage gap is the most consequential policy gap in the ACA. Adults earning below 100% FPL (~$15,060 individual in 2026) can't get ACA marketplace subsidies (subsidies start at 100% FPL) and may not qualify for traditional Medicaid — which in most non-expansion states covers only children, pregnant women, and certain disabled individuals, not childless working-age adults. In Texas, a childless adult with no disability earns roughly $0 in Medicaid eligibility; a parent must earn below roughly $2,600/year ($217/month). You may have literally zero affordable coverage options. Your immediate practical options: find a Federally Qualified Health Center (FQHC) — they provide sliding-scale primary care and many services regardless of ability to pay, at findahealthcenter.hrsa.gov or by calling 1-877-464-4772. For emergencies, hospitals with emergency departments must treat you regardless of ability to pay (EMTALA); hospital billing offices (not front desk staff) handle charity care applications, typically requiring you to apply within 90-240 days of a bill. Some hospitals — particularly nonprofits required to provide community benefit — have charity care programs that forgive or reduce bills for uninsured low-income patients. Ask specifically for the "financial counselor" or "patient assistance program."

If you live in an expansion state and your income hovers near 138% FPL: Medicaid and Marketplace coverage work very differently. Medicaid has no premium, no deductible, and low copays, but provider networks may be narrower and some specialists may not accept it. Marketplace coverage with premium tax credits has modest premiums, some cost-sharing, and typically broader provider access. Income spikes can push you off Medicaid mid-year — and you must report the change and transition to Marketplace coverage promptly to avoid a coverage gap. Gig workers with variable income face this most acutely: a strong work month that pushes projected annual income above 138% FPL ($20,800 individual) requires reporting within 30 days at healthcare.gov or your state exchange. If you don't report and remain on Medicaid ineligibly, you may face repayment demands or disrupted coverage. If your income is volatile, you may want to project conservatively to stay on Marketplace coverage and avoid the mid-year flip.

If you're on Medicaid expansion and the OBBBA work requirements take effect: The OBBBA reconciliation package passed in 2025 includes community engagement (work) requirements for most non-disabled expansion adults ages 19-65, requiring 80 hours per month of work, education, or community service starting in 2026-2027 (implementation dates vary by state). If you're working full-time, this almost certainly doesn't affect you. If you're not currently working, check your state's implementation timeline and exemption categories — exemptions exist for primary caregivers, those with disabilities, medically frail individuals, and others. Your state Medicaid office will notify you of requirements; respond to any notices promptly to avoid losing coverage. Contact your state Medicaid office at medicaid.gov/about-us/contact-us/index.html for state-specific guidance.

If you're approaching 65 and currently on Medicaid: Medicare begins at 65 and is separate from Medicaid eligibility. Once enrolled in Medicare, most Medicaid benefits shift to supplementary coverage. If you qualify for both Medicare and Medicaid ("dual eligible"), Medicaid can cover Medicare premiums, deductibles, and cost-sharing through Medicare Savings Programs — potentially saving $174/month in Part B premiums alone. Four Medicare Savings Programs exist: QMB (pays Part A + Part B premiums, deductibles, and cost-sharing), SLMB (pays Part B premium only), QI (partial Part B premium), and QDWI (for working disabled). Find your state's eligibility rules and application at medicare.gov/medicare-savings-programs or by calling 1-800-MEDICARE (1-800-633-4227). Apply through your state Medicaid office, not Medicare directly.

Implementing Regulations

42 CFR Part 435 — Medicaid eligibility (§§ covering income standards, MAGI-based eligibility groups, expansion populations, categorical eligibility, medically needy)
42 CFR Part 431 — Medicaid state plan requirements (fair hearings, access to services, managed care delivery)
42 CFR Part 433 — State fiscal administration (federal financial participation rates, FMAP calculations)
42 CFR Part 438 — Medicaid managed care (MCO requirements, network adequacy, quality assessment)
42 CFR Part 455 — Program integrity (fraud and abuse detection, provider enrollment, third-party liability)
42 CFR Part 438 — Managed Care (Medicaid managed care organizations; comprehensive risk contract requirements; network adequacy standards; medical loss ratios; quality strategy; appeals and grievances; 104 sections — most Medicaid enrollees today receive benefits through managed care)

Pending Legislation (119th Congress)

S2279 — Protect Medicaid and Rural Hospitals Act (Sen. Hawley, R-MO) — Repeals recent Medicaid provider-tax and state-directed payment changes; adds $10B/year (FY2031-2035) to boost rural hospital funding
HR3321 — Ending Medicaid Discrimination Against the Most Vulnerable Act (Rep. Roy, R-TX) — Phases down the enhanced 90% federal match for expansion adults from 2027-2034, reverting to the standard state match rate
S523 — Protect Medicaid Act (Sen. Cassidy, R-LA) — Bars federal Medicaid funding for administrative costs of state programs serving noncitizens; requires HHS IG report within 180 days
S2069 — Stabilize Medicaid and CHIP Coverage Act (Sen. Whitehouse, D-RI) — Extends 12-month continuous enrollment to all Medicaid and CHIP enrollees nationwide
HR2445 — Ensuring Medicaid Eligibility Act (Rep. Kennedy, R-UT) — Blocks HHS's Medicaid streamlining rule; requires citizenship and quarterly income checks
S447 — Jobs and Opportunities for Medicaid Act (Sen. Kennedy, R-LA) — Conditions Medicaid for able-bodied adults on 20 hours/week of work or volunteer activity, effective Jan 1, 2026
HR3154 — Medicaid Improvement for Insular Areas Act (Del. King-Hinds, R-MP) — Removes federal Medicaid funding caps for Puerto Rico, USVI, Guam, Northern Mariana Islands, and American Samoa
S1903 — Reconciliation protection (Sen. Reed, D-RI) — Would prohibit changes to Medicare and Medicaid through the budget reconciliation process
HR1875 — Medicaid Provider Screening Accountability Act (Rep. Langworthy, R-NY) — Requires states to run monthly cross-state checks of termination records for Medicaid provider enrollment
HR 5815 — DC Medicaid Fairness Act: higher FMAP for Washington, D.C., starting at 70% and stepping down through 2029. Status: Introduced.
S 3690 — Ensuring Access to Medicaid Buy-in Programs Act: Medicaid buy-in for working people with disabilities, remove age limits and add 16+ SSI-related eligibility. Status: Introduced.

Recent Developments

OBBBA Medicaid work requirements (2025): The One Big Beautiful Bill Act included community engagement (work) requirements for Medicaid expansion adults — requiring most non-disabled adults ages 19-65 to document 80 hours per month of work, education, or community service as a condition of continued enrollment. Ten states remain non-expansion (Texas, Florida, Georgia, Wyoming, Kansas, South Carolina, Tennessee, Alabama, Mississippi, Wisconsin) as of 2026; expansion states now face the challenge of implementing work requirement verification without creating substantial administrative lock-out. CBO estimated approximately 10 million people could lose coverage under the OBBBA Medicaid provisions.
Block grant conversion proposals: The OBBBA also included per-capita cap provisions that would shift Medicaid federal financing from an open-ended matching model to a per-beneficiary cap — effectively a form of block granting. Under per-capita caps, states would receive a fixed federal payment per enrollee rather than the current FMAP match (typically 50-77% of costs). States that experience cost growth above the cap rate must absorb the excess from state funds or reduce benefits. The per-capita cap provisions apply to expansion adults first, with potential extension to other Medicaid categories. States that expanded Medicaid now face a difficult fiscal calculation: the coverage they expanded under the ACA may become a budget liability if federal matching rates are capped below actual cost growth.
Non-expansion states and the coverage gap persists: The 10 remaining non-expansion states leave approximately 2-3 million adults in the "coverage gap" — earning too much for traditional Medicaid (which covers primarily children, pregnant women, and certain disabled individuals) but too little for ACA marketplace subsidies (which begin at 100% FPL). Georgia operates a limited partial-expansion waiver (Georgia Pathways) requiring work documentation; enrollment has been minimal due to administrative barriers. Florida, Texas, and the other holdouts have shown no movement toward expansion, and the OBBBA's work requirements reduce the fiscal attractiveness of expansion for Republican-governed states that might have otherwise been persuaded by the 90% federal match rate.