States’ decisions to expand Medicaid or not expand Medicaid have mostly been made based on political support or opposition of the Affordable Care Act (ACA). This year with some states having new Governors and political parties as the majority, we are already seeing some flipping of states’ decisions on Medicaid expansion.

Indiana is the latest state to expand Medicaid, making it the 28th state to implement the program. Indiana’s plan, like Arkansas’ model, incorporates components which were outside the box of the original ACA Medicaid expansion. In January, Indiana’s waiver was approved.

Under Indiana’s plan, people with incomes above the federal poverty level ($11,670 for an individual) must contribute to a health savings account or be locked out of coverage for six months.  

Since the November elections, governors in Alaska, Idaho, Montana, Tennessee, Utah and Wyoming have been trying to get their legislatures to support their plans to expand Medicaid. Tennessee's plans came to a quick halt with a 7-4 vote against the plan by the state Senate Health and Welfare Committee after three days of testimony on both sides of the issue. Alabama, North Carolina and Texas governors said for the first time they were open to the idea of expanding Medicaid. Other than Arkansas, no Southern state has expanded Medicaid. If Florida and Texas vote for expansion, an additional 2.6 million people could become part of  the Medicaid rolls. Both states are not likely to be successful in passing Medicaid expansion legislation.

While Kansas governor Sam Brownback continues to oppose Medicaid expansion, a legislative committee known as Vision 2020 has been holding hearings on expansion and unveiled legislation in February. Kansas hospitals have been drafting their own proposal, which draws on approaches in other states such as Indiana and Arkansas.

Iowa will start charging monthly premiums of $5 to $10 to anyone in their Medicaid expansion program who does not complete an annual health exam and online questionnaire. So far, only 17,000 out of the 119,000 enrollees have completed both.

In Arizona, former governor Jan Brewer infuriated Republican lawmakers when she strong-armed the Medicaid expansion through the Arizona legislature in 2013. More than 230,000 Arizonans enrolled under the new rules as of October of last year, the state reported.

Figure 1

New governor Doug Ducey, also a Republican, hasn’t indicated he is interested in undoing the expansion, but he wants the state to seek federal approval to alter the program, including adding a requirement that beneficiaries deposit money into health savings accounts.

We may see some states announce plans to end their Medicaid expansion programs. Arkansas, a state that received publicity for their innovative model of Medicaid expansion, now has a new governor who states that the program will end after 2016. Under the Medicaid expansion that is part of the ACA, the federal government pays the full price for covering newly eligible adults with incomes up to 138% of the federal poverty level ($16,105) through 2016 and then gradually lowers its share to 90% in 2020 and beyond.

Politics as well as costs to the states will remain the driving forces in decisions surrounding Medicaid expansion.


Lucey C. Some Iowans will face premiums for Medicaid expansion. The Des Moines Register, February 1, 2015

Pradhan R. Kansas lawmakers try to stir some Medicaid motion., February 3, 2015

Vestal C. More states lean toward Medicaid expansion., January 28, 2015