Why haven’t all states
expanded coverage?
In its June 2012 ruling on the
constitutionality of the ACA, the
U.S. Supreme Court determined
that the expansion as drafted
was too coercive to the states,
but left the rest of the law largely
in place. This caveat effectively
made expansion voluntary, yet
with full federal funding during
the first few transition years.
As of the beginning of
March 2016, 31 states plus
the District of Columbia had
expanded coverage, including
seven states that chose to do
so under a waiver (although
Pennsylvania later transitioned
to a more traditional system).*
States that have chosen not
to expand have cited several
concerns, including the
federal government’s ability to
maintain its share of funding,
cost of the expansion to the
state once the period of full
federal funding ends, and
general opposition to the ACA.
How has Medicaid
expansion affected coverage
rates in the states?
According to the Kaiser
Commission on Medicaid
and the Uninsured, Medicaid
enrollment in 2015 increased
18 percent across the 32
expansion areas (including
DC), and some states saw much
higher increases than had
been projected due to pent-up
demand for coverage among
the uninsured.† In those states
that did not expand Medicaid,
enrollment increased by
5. 1 percent. Some of the increase
in non-expansion states is
attributable to those individuals
who went to the exchange to
Kaiser Commission on Medicaid and the
Uninsured: Medicaid enrollment and
spending growth: FY 2015 and 2016. Available
at: http://kff.org/medicaid/issue-brief/
medicaid-enrollment-spending-growth-
fy-2015-2016/. Accessed March 8, 2016.
† The Henry J. Kaiser Family Foundation.
Status of state action on the Medicaid
expansion decision. Available at: http://
kff.org/health-reform/state-indicator/
state-activity-around-expanding-medicaid-under-the-affordable-care-act/. Accessed March 14, 2016.
FIGURE 1. MEDICAID EXPANSION BY STATE
V101 No 5 BULLETIN American College of Surgeons
38 |
WHAT SURGEONS SHOULD KNOW ABOUT...
KE Y:
19 states are not
expanding Medicaid
26 states (including
District of Columbia) are
expanding Medicaid
Six states are expanding
Medicaid, but using an
alternative to traditional
expansion
