On tap for 2023: Medicaid expansion in the states? 


January 6, 2023

This year could be key for efforts to expand Medicaid coverage in 11 “non-expansion” states as increased public pressure is converging with key state Republican leaders changing their mind on the issue and softening their opposition. 

Technically, there are currently 12 states that have not expanded Medicaid coverage: Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming. However, voters in one of those 12 states, South Dakota, voted this past November to expand. The new law takes effect on July 1 of this year. Unlike other states where Republican governors or legislators have dragged their feet after similar referendum results, South Dakota Republicans are not standing in the way of expansion efforts. 

States that opt to expand their Medicaid programs under the terms of the Affordable Care Act extend coverage to adults under age 65 with incomes up to 138 percent of the federal poverty line. The federal government pays 90 percent of the expansion cost. Estimates vary as to how many Americans would gain access to coverage if all of the non-expansion states expanded Medicaid. A 2021 Kaiser Family Foundation analysis placed the number at just over 2 million. But an Urban Institute study puts the number much higher – at 3.7 million. Both groups agree that a majority of those residents newly gaining coverage would be people of color. 

In 2023, serious debates over Medicaid expansion are expected in at least half of the non-expansion states. Here is a quick rundown: 

In North Carolina, which could well become the next expansion state after South Dakota, a minor political earthquake occurred last spring, when Senate Republican Leader Phil Berger, a longtime staunch opponent of expansion, completely reversed his position, saying his state needs to do more to provide health care for the working poor. “If there is a person that has spoken out more against Medicaid expansion than I have, I’d like to meet that person,” he said. “In fact, I’d like to talk to that person about why my view on this has changed.”

Berger also said he came to see how many of the people who would receive expanded Medicaid benefits were not free-riding on the system, but were people who were working at jobs in the food industry, as farm workers, even as church pastors. “I don’t know that I had the right focus as far as the incentives are concerned,” Berger said

Both the North Carolina House and Senate actually have passed competing versions of an expansion bill; but in 2022, time ran out in the legislative calendar before they could reach agreement on final legislation. The state’s Democratic governor, Roy Cooper, supports expansion. 

In Wyoming, a bill expanding Medicaid passed the House in 2021, but failed to get a vote in the Senate. In 2022, the measure did get a vote in the Senate but failed to pass. Advocates say the bipartisan legislation will be introduced again in 2023. 

In Alabama, the former Republican governor, himself a physician who used to oppose Medicaid expansion, now says he supports it because it would help the state’s rural areas. 

In Georgia, where rural health care is also a huge issue, Brian Robinson, former spokesman for the first governor to reject Medicaid expansion, now says it’s time to reverse course. He told Axios Atlanta that such a move would allow Republicans to “steal an issue” from Democrats, acknowledging that many more voters agree with expansion than disagree. Both Democrats and Republicans are now having meetings in their respective caucuses to discuss how to proceed. 

In Tennessee, the state’s Republican lieutenant governor has left the door open for expansion ever since more money for states was included as part of the 2021 American Rescue Plan. However, no serious effort at passage has been mounted. 

And in Texas, Democratic and Republican legislators will, once again, sponsor bipartisan expansion legislation when the Texas Legislature convenes next week. Expansion, however, is unlikely despite the fact that Texas has the highest rate of uninsured residents in the nation and despite polling that shows the public is overwhelmingly in favor of expansion. The reason progress on the issue is unlikely is due to staunch opposition from Texas Gov. Greg Abbott, a potential presidential candidate, and from the state’s powerful lieutenant governor. 

All in all, though, expansion advocates are pleased with progress they have made. “There is real momentum on Medicaid expansion in these conservative states that have been holding out,” Melissa Burroughs of Families USA told Axios. She said there are Republicans championing or discussing expansion in every non-expansion state but often “political dynamics and leadership” stand in the way. 

The Commonwealth Fund, which has been closely tracking Medicaid expansion efforts, expressed similar optimism. 

“South Dakota, Wyoming, and North Dakota are the latest states to make major progress toward expansion, and if those efforts succeed, they could help build momentum in other holdout states,” the Fund wrote in a blog post. “The expected coverage losses following the end of the public health emergency also could breathe new life into previously stalled efforts. Given these dynamics, expansion will continue to be an issue to watch in state legislative sessions in 2023 and beyond; in the meantime, 12 states continue to leave millions of their residents without affordable health care options.” 

Affordable Care Act