CFED Scorecard

CFED Assets & Opportunity Scorecard

Medicaid Expansion Reports & Graphics Policy Brief


States that Have Elected to Expand Medicaid

Health insurance is one of the most important protections against loss of a family’s assets. It mitigates the cost to a family of a medical emergency or the treatment of a chronic illness—expenses that might otherwise require a family to spend long-term savings, sell assets or go into debt. One public program that aims to ensure that low-income families have insurance is Medicaid, which covers parents receiving cash assistance, low-income children and pregnant women.

In 2010, Congress enacted the Affordable Care Act (ACA), which, among other reforms, expanded Medicaid coverage to nearly all nonelderly individuals with incomes at or below 138% of the federal poverty level. This expansion would have meant that non-disabled, childless adults—who had generally been excluded from Medicaid coverage—would be covered. However, in 2012, the United States Supreme Court ruled that expansion was “unconstitutionally coercive” of states, making expansion of coverage of these groups optional for all states.

What States Can Do

All states can elect to expand Medicaid coverage to at least 138% of the federal poverty level. Expanding income eligibility for Medicaid extends coverage to millions of currently uninsured adults eligible for the program.

Strength of State Policies: Medicaid Expansion

Has the state expanded Medicaid to those earning 138% or
more of federal poverty level?
expansion? 1
Income Eligibility
(Parents)  2
Income Eligibility
(Other non-disabled
adults) 2
Alabama    16%  0% 
Alaska    128%  0% 
Arizona    138%  138% 
Arkansas    138%  138% 
California    138%  138% 
Colorado    138%  138% 
Connecticut 3   201%  138% 
Delaware    138%  138% 
District of Columbia 3   220%  215% 
Florida    35%  0% 
Georgia    39%  0% 
Hawaii    138%  138% 
Idaho    27%  0% 
Illinois    138%  138% 
Indiana    24%  0% 
Iowa    138%  138% 
Kansas    38%  0% 
Kentucky    138%  138% 
Louisiana    24%  0% 
Maine    105%  0% 
Maryland    138%  138% 
Massachusetts    138%  138% 
Michigan    138%  138% 
Minnesota 3   205%  205% 
Mississippi    29%  0% 
Missouri    24%  0% 
Montana    52%  0% 
Nebraska    55%  0% 
Nevada    138%  138% 
New Hampshire    75%  0% 
New Jersey    138%  138% 
New Mexico    138%  138% 
New York    138%  138% 
North Carolina    45%  0% 
North Dakota    138%  138% 
Ohio    138%  138% 
Oklahoma    48%  0% 
Oregon    138%  138% 
Pennsylvania    38%  0% 
Rhode Island    138%  138% 
South Carolina    67%  0% 
South Dakota    54%  0% 
Tennessee    111%  0% 
Texas    19%  0% 
Utah    47%  0% 
Vermont    138%  138% 
Virginia    52%  0% 
Washington    138%  138% 
West Virginia    138%  138% 
Wisconsin    100%  100% 
Wyoming    59%  0% 

Notes on the Data

1. "Status of State Action on the Medicaid Expansion Decision, as of December 11, 2013," Kaiser Family Foundation State Health Facts. Accessed December 17, 2013.

2. "Medicaid Income Eligibility Limits for Adults at Application, Effective January 1, 2014," Kaiser Family Foundation State Health Facts. Accessed December 17, 2013.

3. Connecticut, the District of Columbia, and Minnesota had previously expanded Medicaid to parents with incomes above 138% FPL and are maintaining these higher limits.

What States Have Done

As of December 2013, 25 states and the District of Columbia have expanded Medicaid eligibility to those with incomes of 138% or more of the federal poverty level.

Making the Case

Since 2007, CFED has provided tips to help advocates build a campaign to advance asset-building policies. Although the specific policies featured in the Scorecard have changed over the years, the strategies discussed in this section are still applicable and can be used to make the case for a number of related policies.

Strategies for a Successful Campaign

To expand access to quality health care in the current political environment, state advocates should defend the PPACA and push for quick implementation of key reforms. To garner support for reform, advocates should:1

1. Identify key constituencies and partners who benefit from reform. Think of the populations that will benefit from reforms, which include small business owners, the chronically ill, young adults and seniors. Consider partnering with relevant groups such as local small business groups, diagnosis specific advocacy organizations, senior organizations or college groups.

2. Hold public events to educate key constituencies about new benefits. Examples include: an event at a local senior center to explain what health reform means to older adults, or distributing information at a university’s job fair for young adults who will continue to be covered under their parent’s insurance post-graduation.

3. Collect stories. Collect testimonies of people who have benefited from Medicaid. Real life stories shift the discussion away from politics and toward taking care of people. The Kaiser Family Foundation’s Faces of Medicaid report series and Utah Health Policy Project’s Storybank provide numerous examples of stories that show the face of Medicaid beneficiaries, including children, seniors and people with disabilities.

4. Engage the media. Engaging the media helps spread the message to a larger audience. Notifying the media prior to public events, writing letters to the editor and op-eds to the local newspaper, and maintaining a presence on blogs and social networking sites are all ways to raise attention about the benefits of reform and the importance of expanding coverage.

5. Develop implementation priority agendas. States can pursue a number of opportunities made available through PPACA, and advocates should help the state identify which opportunities will most benefit its residents. Developing an implementation priority agenda will help states prepare for the steps they must take to comply with the law as well as any grants or pilot programs in which they may want to participate.

6. Participate in decision-making bodies. A variety of new and existing boards and commissions are making key decisions as PPACA is implemented across states. It is crucial that consumer advocates proactively seek the chance to participate in these conversations.


Key Messaging to Defend Medicare

In addition to promoting implementation of key reforms, states should defend Medicaid from cuts in the current budgetary climate. Key messages in support of Medicaid include:2

1. Medicaid increases access to care, decreases debt and improves health.3 A recent study found that Medicaid increased health care utilization rates, decreased liabilities and out-of-pocket costs and increased well-being. Using Oregon’s lottery system to compare Medicaid recipients to nonMedicaid recipients, the study found:

  • Those with insurance coverage were 30% more likely to use a hospital, 15% more likely to take prescription drugs and 21% more likely to have an outpatient visit.
  • The insured group was also 25% less likely to have unpaid medical bills sent to a collection agency and 20% less likely to have any out-of-pocket costs.
  • The Medicaid group was more likely to screen negative for depression and report good health and overall happiness in the past six months.

2. Medicaid benefits members of the community. Medicaid benefits more than the patients it serves. Medicaid supports health care providers, including physicians, nurses, community health centers, mental health providers and hospitals. Medicaid also benefits employers and even those who are insured – without Medicaid, premiums would increase because costs of covering the uninsured would shift to the private market. Finally, Medicaid benefits the community as a whole by limiting the negative effects of high rates of uninsured, such as emergency room overcrowding and losses in productivity.

3. The majority of Americans support Medicaid, even during periods of budget deficits. According to a 2005 survey by the Kaiser Family Foundation, 74% of adults said Medicaid is a “very important” government program. The survey found that although almost two-thirds of the public thought their state’s budget was either in crisis or had major problems, half said they “strongly” opposed and another 22% “somewhat” opposed cutting back on their state’s Medicaid program to balance the budget.

4. Medicaid leverages federal dollars and limits costs of emergency care. The federal government matches state investment in Medicaid, at a minimum of a 1:1 ratio, which means that states that cut their Medicaid programs will lose federal dollars. In addition to forfeiting matching funds, the cost of covering emergency health care for a greater number of uninsured people will increase, and these costs will be shifted to the state and private businesses.

5. There are alternatives to cuts. States can maximize Medicaid revenue by charging providers a fee, which was the case in Colorado, or increasing tobacco taxes in order to leverage additional federal dollars, as was the scenario in Arkansas. States can also reform payment and delivery systems to reduce costs by increasing use of generic drugs, eliminating payments for preventable errors like hospital-acquired infections and implementing patient-centered medical homes. Finally, states can implement public health campaigns to reduce tobacco use, prevent HIV transmission and increase vaccinations.


1  This section is adapted from: “State Implementation of National Health Care Reform: Strategies for Public Outreach,” Community Catalyst, May 2010, (Accessed August 2011).

2  With the exception of message #1, this section has been adapted from: “Defending Medicaid in Hard Times: A Guide for State Advocates,” Community Catalyst, (Accessed August 2011).

3  Amy Finkelstein, et al., The Oregon Health Insurance Experiment: Evidence from the First Year, (Cambridge, MA: National Bureau of Economic Research, 2011).

Case Studies

Since 2007, CFED has provided case studies that capture detailed stories of noteworthy state policy changes.  Although the specific policies featured in the Scorecard have changed over the years, these case studies still serve as instructive lessons drawn from both policy victories and defeats.

Expanding Medicaid in Colorado (published October 2011)
In 2009, the Colorado General Assembly passed House Bill 09-1293, the Colorado Health Care Affordability Act. The Act created a Hospital Provider Fee that generates enough revenue to increase payments to hospitals for providing care to Medicaid and indigent populations, as well as revenue to implement significant expansions of the Medicaid and CHIP programs. Click here to read more.

The Return of Adult Dental in Michigan (published October 2011)
In June 2009, the Michigan Oral Health Coalition – a coalition focused on improving the oral health of Michigan residents through partnerships with providers, educators, legislators, policymakers and the community – launched an advocacy campaign to reinstate Medicaid adult dental services eliminated earlier that year. Click here to read more.

Progress and Challenges in Texas (published September 2009)
Texas enacted CHIP legislation in 1999 and, despite this late start, experienced robust early enrollment. More than 500,000 children were soon covered in its separate state CHIP program… The success of these policies in reaching eligible uninsured children has not been welcomed by all lawmakers in Texas’s socially conservative, low-tax, low public service political context. During the 2003 recession, lawmakers cut CHIP continuous eligibility from 12 months to six, resulting in enrollment dropping by 40%. Click here to read more.

Expanding Coverage in Massachusetts (updated September 2009)
In 2006, Massachusetts enacted a far-reaching health care reform plan that expanded access to health insurance for the uninsured. The plan includes significant expansions in subsidized public coverage for low-income families and childless adults. The reform succeeded in reducing the number of uninsured in Massachusetts – as of 2008, only 2.6% of the population was uninsured. The decline in the uninsured population in the state accounted for 22% of the total drop in nonelderly uninsured nationally. Click here to read more.

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