The Implications of Medicaid Expansion in the Remaining States: 2020 Update

A nurse goes over a patient's medicines in a doctor's office.

Even absent the current COVID-19-related economic crisis, if the 15 holdout states had expanded Medicaid eligibility as envisioned under the ACA, 3.9 million fewer people would have been uninsured.

The Issue

Under the Affordable Care Act (ACA), states have the option to expand Medicaid eligibility for nonelderly people up to 138 percent of the federal poverty level (FPL). As of January 2020, 35 states and the District of Columbia had expanded and 15 states had not.

Key Findings

Using the latest available data on Medicaid and marketplace enrollment, researchers find that if the 15 holdout states had expanded Medicaid eligibility as envisioned under the ACA, 3.9 million fewer people would have been uninsured and 4.1 million people in nonexpansion states would have gained health insurance that met ACA standards.

  • In typical circumstances, Medicaid expansion in the remaining 15 states would lead to an overall 28 percent reduction in the number of uninsured people in those states combined.

  • The declines in uninsured residents would be far more significant in some states, including Alabama (43.1%), Mississippi (39.0%), Missouri (36.4%), and South Carolina (36.3%).

  • Wisconsin, which already provides Medicaid for many poor adults, would see the smallest percentage decrease in the uninsured (16.0%) under expansion.

Conclusion

The COVID-19 pandemic has resulted in tremendous job loss. Since the health insurance of many Americans is tied to their employment, the United States is likely to experience large decreases in private insurance coverage. Consequently, Medicaid expansions in the remaining 15 states would lead to even larger gains in insurance coverage during the pandemic-driven economic downturn than the results presented, which were estimated without accounting for the effects of the pandemic.

About the Urban Institute

The nonprofit Urban Institute is dedicated to elevating the debate on social and economic policy. For nearly five decades, Urban scholars have conducted research and offered evidence-based solutions that improve lives and strengthen communities across a rapidly urbanizing world. Their objective research helps expand opportunities for all, reduce hardship among the most vulnerable, and strengthen the effectiveness of the public sector. Visit the Urban Institute’s Health Policy Center for more information specific to its staff and its recent research.