The National Context for Medicaid Expansion

Blog | November 7, 2018


By Adam Zolotor, MD, DrPH


Today is post-election day. No matter your side, there were winners and losers. But there were some clear winners - those set to be newly eligible for Medicaid in Nebraska, Idaho, and Utah - as well as possibly those in Maine and Kansas. That would bring the total to 37 states expanding Medicaid under the Affordable Care Act. Here is a quick look at what went down:


  • Voters in Idaho, Nebraska, and Utah voted for ballot measures that support Medicaid expansion.
  • The incoming governor of Maine is expected to honor the 2017 referendum in favor of expansion that has been blocked by outgoing Governor Paul LePage.
  • Kansas' incoming governor favors Medicaid expansion. The state legislature of Kansas previously voted for a law to expand Medicaid (passing in both chambers) but outgoing Governor Sam Brownback vetoed the expansion bill. If the state legislature were to vote to expand Medicaid again, the incoming governor would sign the bill.
  • Voters in Montana failed to adopt a ballot measure that would eliminate their current Medicaid expansion sunset provision and pay for additional costs with an increase in tobacco tax. Medicaid expansion will sunset in June 2019 without a change in law.


Medicaid enrollment has increased in expansion states by a total of 13.6 million people. If these five states successfully implement Medicaid expansion, an additional 317,000 people without insurance will be eligible for Medicaid, the vast majority of whom work, or live in a household with a working adult. The federal government (and all American taxpayers) currently pay 94% of this cost. In 2020 and beyond, the federal government share of that cost will be 90%.


North Carolinians already pay about $1 billion per year of the cost of Medicaid expansion in other states.  As more states expand Medicaid, this cost to North Carolinians will increase and we will accrue none of the benefit in terms of an insured and healthier population, new jobs (estimated at 43,000), and economic stimulus. Expanding Medicaid, as recommended by North Carolina Institute of Medicine task forces, comes at a very low cost (a cost borne by health systems in some proposals), would insure 339,000 North Carolinas, and would be a huge jobs and economic boon to North Carolina.