Health Care

The outlook for Medicaid expansion in holdout states

There are only 10 states, all with GOP-led legislatures and mostly in the South, that have not expanded the program.
Alabama House Speaker Nathaniel Ledbetter (R) speaks to reporters on Friday, July 21, 2023, at the Statehouse in Montgomery, Ala. (AP Photo/Jeff Amy)

Medicaid expansion is attracting a fresh look from Republican leaders in at least three of the 10 states that have so far declined to participate in the program — Alabama, Georgia and Mississippi — as they seek solutions to a wave of hospital closures and high uninsurance rates among the working poor.

“You know the problem that we’ve got right now, we’ve got so many hospitals that are in dire straits,” Alabama House Speaker Nathaniel Ledbetter (R) said this week. “We’ve got to have the conversation. We cannot not have it.”

Under the 2010 Affordable Care Act, states can get extra federal money if they expand Medicaid eligibility to nearly all adults with incomes up to 138% of the Federal Poverty Level ($20,120 for an individual in 2023). Expanding removes other state-by-state eligibility requirements.

States that have not expanded Medicaid have larger numbers of people who fall in the gap of people who earn too much to qualify for Medicaid but not enough to qualify for Affordable Care Act marketplace assistance, because they have incomes below the poverty line. That was one of the arguments that helped win over opponents in North Carolina, which expanded last year.

Proposals in non-expansion states include combining Medicaid expansion with a relaxation of so-called Certificate of Need Laws, which require hospitals and medical offices that want to open new facilities to get special approval before they open new facilities. Arkansas, among the first southern states to expand and the only state that used its federal expansion money to buy private insurance for the uninsured, is serving as another model.

Here’s a look at where the conversation stands at the outset of the 2024 legislative sessions in the 10 non-expansion states.


The Republican-controlled state legislature held the state’s first committee hearing on closing the coverage gap last March, after resisting talk of Medicaid expansion for years. Testimony came from the state Hospital Association, a longtime advocate for expansion, and Blue Cross Blue Shield of Alabama, the state’s largest private insurance provider.

Advocates who spoke to Pluribus News called the hearing “a huge step forward.” But the biggest shift could happen behind the scenes.

The Alabama Hospital Association has said it is working on an “Alabama-specific” expansion that would draw on experiences in other states, especially Arkansas. That model of using the extra federal money to buy residents private insurance would require obtaining a waiver from the federal government.


Florida Senate President Kathleen Passidomo’s (R) health care overhaul — a priority during the 2024 legislative session — left out Medicaid expansion. That’s about as good an indication as any that the idea is unlikely to find support among the state’s Republican leaders.


After more than a decade of steadfast opposition, some Georgia Republicans including House Speaker Jon Burns have said they are open to a proposal to adopt an Arkansas-style Medicaid expansion as part of a compromise to relax Certificate of Need laws, a priority of Lt. Gov. Burt Jones.

Combining the two could draw Democratic support for the Certificate of Need law overhaul and diffuse Democratic criticism during the 2024 presidential elections, when Georgia is again expected to play a pivotal role. Gov. Brian Kemp (R) has opposed Medicaid expansion. But his alternative plan — a limited extension of the program to people who meet work or activity requirements — has fallen far short of enrollment projections.


Gov. Laura Kelly (D) introduced a Medicaid expansion bill every year since she was first elected in 2018, noting that polls show that solid majorities of Kansas residents support the idea. Her latest attempt to get the Republican-controlled legislature on board would include work requirements, a GOP-favored provision that Democrats have rejected in the past.

The proposal was met with immediate opposition from House and Senate Republican leaders. In-state advocates say any expansion plan will be a heavy lift in a state that is home to conservative billionaire Charles Koch. The Koch political network has waged a years-long battle against Medicaid expansion and has spent tens of millions of dollars on civic projects in the Wichita area, where both the Senate and House GOP leaders live.


New House Speaker Jason White (R) has promised to give Medicaid expansion serious consideration starting this session in a remarkable shift from his predecessor Philip Gunn (R), who refused to hold hearings on the issue.

Mississippi Lt. Gov. Delbert Hosemann (R), who presides over the Senate, said before he was elected to his first term in 2019 that he would entertain the idea. Gov. Tate Reeves (R) was challenged on his long-held opposition to expansion during his competitive re-election campaign last year.

South Carolina

Advocates in South Carolina have been working on building support from the public and putting together a community coalition, based in part on the campaign that helped it pass in North Carolina.

But with the entire House up for re-election this year and an internal power struggle already brewing between moderates and the hardline Freedom Caucus, advocates are aware that Republican lawmakers might attract a challenge from their right if they publicly support a plan. For that reason, don’t expect much talk of an expansion plan in the legislature until after the June primary.


Rep. Sam Whitson (R) said in December he was trying to amass support to reverse a 2014 resolution in Tennessee requiring legislative approval for Medicaid expansion. That measure was put in place to quash a deal then-Gov. Bill Haslam (R) was negotiating with the federal government.

It is unclear whether giving the authority back to the governor would change much in the short term. Gov. Bill Lee (R) opposes it.


Gov. Gregg Abbott (R) and Lt. Gov. Dan Patrick (R) have been among the country’s leading opponents to Medicaid expansion since Abbott, then the Texas attorney general, filed a 2010 lawsuit to get the Affordable Care Act thrown out. Supporters, including Democratic sponsors of past expansion bills in the House and Senate, have expressed doubt that the state’s Republican leadership will soften its opposition any time soon.


Medicaid expansion is a priority of Gov. Tony Evers (D). But he hasn’t convinced Republicans who control the Wisconsin legislature.

“As long as I am the Assembly speaker, Medicaid expansion will never happen,” Republican House Speaker Robin Vos said in June. “There is not a single person who would benefit from Medicaid expansion that does not already qualify for either free or super-duper, duper, duper cheap Obamacare.”


Senate President Ogden Driskill (R) said last year that although he doesn’t support Medicaid expansion, he would be open to a discussion on it. Regardless, the Wyoming Senate voted it down yet again last year, through a Republican senator-led amendment to the state’s supplemental budget.

Advocates in the state say they are optimistic of a breakthrough soon. But maybe not this year, when in the short “budget session” non-budget bills face a higher vote threshold for introduction.