Why millions of people could lose Medicaid next month

State lawmakers in North Carolina reached a deal Thursday on Medicaid expansion, ending a decadelong fight in the state over whether to accept federal funding to expand the program that will provide health coverage to low-income adults.

The agreement in North Carolina on the 13th anniversary of the Obama-era Affordable Care Act, which offered the Medicaid expansion to states, knocks one more state off the list of Medicaid expansion holdouts, as an overwhelming majority of states have accepted the federal support.

But even as Democrats in Congress try to entice state lawmakers to accept federal funds to expand Medicaid, a dwindling number of states have continued to turn their noses up at the offer. Here are the states that still have not adopted the Affordable Care Act’s Medicaid expansion.

Ten states have yet to adopt Medicaid expansion

With North Carolina lawmakers announcing they have reached a deal to expand Medicaid, that leaves 10 states that have not accepted the expansion, all of which either have a legislature controlled by Republicans or have a Republican as governor.

Wyoming, Kansas, Texas, Wisconsin, Tennessee, Mississippi, Alabama, Georgia, South Carolina and Florida have yet to adopt the expansion of Medicaid, leaving over 2.1 million people in the “coverage gap” — meaning they fall into the income level that would make them eligible for Medicaid but cannot access it because their state has not adopted it, according to the Center on Budget and Policy Priorities.

South Dakota has adopted the expansion but has not yet implemented it, which is planned for later this year.

Why have those states not adopted the Medicaid expansion?

The Medicaid expansion handed down in former President Obama’s landmark Affordable Care Act law has long been subject to partisan debate. 

The law was championed by Obama and Democrats as a step in the right direction toward universal health care coverage and lowering health care costs. But Republicans argue it is an overstep of the federal government into the free market, raising costs and threatening coverage quality.

Republican lawmakers at the state level have stuck closely to the argument that the Medicaid expansion is an overstep of the federal government, criticizing the amount of spending the government is doing rather than letting private insurers navigate the market themselves. 

But Democrats have kept their foot on the pedal of trying to get Republican states to adopt the expansion, dangling financial incentives to make the change. Under the original Affordable Care Act expansion, the federal government commits to a 90 percent matching rate of funds used to expand the program. The 2021 American Rescue Plan placed even more incentives for states, offering another 5 percent match of federal funds for two years if the remaining holdout states adopt the expansion. 

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