The United States has struggled for years to have an affordable and comprehensive healthcare system, which shelters as many people as possible, especially the most vulnerable, or low-income.
That’s why, during the era of Barack Obama, the Affordable Care Act (ACA) was passed, which popularly began to be called “Obamacare” by the public. The ACA expanded eligibility for Medicaid, a health insurance program for low-income people. Initially, Medicaid only covered certain specific groups (such as children, pregnant women, and people with disabilities).
With the expansion of this eligibility, other adults with incomes up to 138% of the federal poverty level each year were also included. However, not all states adopted this expansion, which has resulted in significant differences in Medicaid access by state.
The ACA also established some new regulations, such as the creation of Health Insurance Marketplaces, the prohibition of discrimination based on pre-existing conditions, the individual mandate or mandatory to purchase health insurance (to ensure that both healthy and sick people were enrolled in health plans, which would help keep costs under control), and special coverage for young adults, among others.
States That Have Expanded Medicaid, Following the Affordable Care Act (ACA)
As of 2024, most American states have adhered to the ACA in some particular way, depending on their local realities and financial possibilities.
These states have chosen to expand Medicaid under the provisions of the ACA, which has allowed more low-income people to access health care:
- West: California, Oregon, Washington, Nevada, Colorado, New Mexico.
- Midwest: Illinois, Michigan, Minnesota, Ohio, Wisconsin, Iowa, Nebraska, Indiana, Kentucky, North Dakota.
- Northeast: New York, New Jersey, Massachusetts, Connecticut, Rhode Island, Vermont, New Hampshire,
- Pennsylvania, Delaware, Maryland.
- South: Arkansas, Louisiana, Virginia, West Virginia, Kentucky (although there have been variations in its implementation), Missouri, Oklahoma.
- Southeast: Arizona, Montana, Utah.
- Alaska
- Hawaii
The following states have not signed up to the expansion of Medicaid medical services
- South: Texas, Florida, Georgia, Tennessee, North Carolina, South Carolina, Alabama, Mississippi.
- Midwest: Kansas, South Dakota, Wyoming.
- Southeast: Idaho, Wisconsin (although it has a limited expansion version).
North Carolina is at an intermediate point, actually, since the state Congress agreed to implement Obamacare, but it still came into effect, but it will be from December 1, 2024.
To date, 273,000 people have signed up, according to the North Carolina Department of Health and Human Services. With this, hundreds of thousands of low-income residents in NC will begin the year 2025 by becoming eligible for Medicaid healthcare.
The expansion raised the state’s long-standing income limit for Medicaid eligibility, extending eligibility to adults who represent up to 138 percent of the federal poverty level for their family size. The previous limit was 100 percent, which prevented many single residents without children from qualifying.
What states are doing for People Without Medicaid
In the last year, several states in the United States have implemented expansions in Medicaid coverage under the Affordable Care Act. In South Dakota and North Carolina, Medicaid coverage was expanded, and in the first eight months of implementation, approximately 22,000 people were enrolled.
In July, Oregon introduced a Medicaid-like coverage option for people whose income exceeds federal eligibility limits. This plan is available to adults with incomes between 138% and 200% of the federal poverty level, which equates to a maximum of $30,120 per person. To date, more than 50,000 people have enrolled in this program, according to data from state officials.
In January, a federal law forced states to ensure that children maintain Medicaid coverage for at least a year after enrollment. Some states have extended this protection: Oregon, New Mexico and Washington allow children to stay covered until the age of six, while California passed a law to extend continuous eligibility until the age of four, although it has not yet been implemented.
Arizona, Maine, and North Dakota
Additionally, three states – Arizona, Maine, and North Dakota – have raised income thresholds to make more children eligible for Medicaid. Utah has begun offering Medicaid-like coverage for children regardless of immigration status, though the program is limited to 2,000 children.
Coverage for pregnant women has also been expanded in several states. Nevada, North Dakota and Tennessee have adjusted income requirements to make it easier for pregnant women to access Medicaid. Alabama and Maryland have expanded eligibility to include pregnant women regardless of immigration status.
Maine, Oregon, and Vermont
Maine, Oregon, and Vermont have extended postpartum coverage from two to twelve months, leading to 47 states now offering a full year of postpartum coverage.
In June, five states – Illinois, Kentucky, Oregon, Utah and Vermont — received federal government approval to extend Medicaid coverage to incarcerated people for the 90 days prior to their release. These states will join others, such as California, Massachusetts, Montana and Washington, that already offer such coverage.
The expansion of Medicaid eligibility usually occurs during periods of economic growth, when states have more income. However, other factors, such as rising maternal mortality and new restrictions on abortion, have driven the expansion of coverage for pregnant women, according to Allison Orris, a researcher at the Center on Budget and Policy Priorities.
The COVID-19 pandemic has also influenced states’ Medicaid decisions. During the pandemic, states were prohibited from withdrawing Medicaid coverage from people who were no longer eligible, as a condition of receiving additional federal funding. This experience highlighted the benefits of maintaining continuous enrollment, which brought the uninsured rate to an all-time low of 7.7%.
However, the reversal of these policies has raised concerns. A survey conducted by KFF in April found that 23% of adults were uninsured after being discharged from Medicaid in 2023. A report from the Centers for Disease Control and Prevention indicated that the uninsured rate increased to 8.2% in the first quarter of 2024, compared to 7.7% in the same period in 2023.