Ten States Are Still Standing Strong Against Government Expansion

A s policy wonks analyze the details of House Republicans’ proposal to reform Medicaid, it’s worth remembering how the program transformed under the Affordable Care Act (ACA). President Obama’s signature law shifted Medicaid from its original purpose — providing health care for the most vulnerable — to covering able-bodied, working-age adults.

Although the legislation initially mandated state expansion, the Supreme Court ruled in NFIB v. Sebelius that this requirement was unconstitutional. Even after the mandate was struck down, Obama’s vision of setting the groundwork for Medicaid for All persisted, effectively bribing states with federal taxpayer dollars to expand coverage. Today, Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming remain the last principled states resisting the tide of expansion.

Medicaid expansion is not just a policy debate; it’s a fight for the future of health care in the United States. In any battle, there’s wisdom in fortifying key positions to avoid losing the entire war. With only ten states remaining as non-expansion holdouts, the push for universal Medicaid is closing in.

Republicans on the Hill should keep this in mind as reform discussions continue. If policymakers fail to address the incentives that pressure states into expansion, they risk ceding all remaining ground to those advocating for government-run health care.

The principled states should not be forced into expansion by federal carrots and sticks. Currently, states receive $9 in federal dollars for every $1 they spend on Medicaid for able-bodied adults, but they receive only $1.33 for every $1 spent on the disabled, pregnant moms, kids, and the elderly in nursing homes.

These incentives are morally flawed, pushing states to prioritize coverage for healthier adults over those who are truly vulnerable. This imbalance also affects the quality of care in expansion states, where many health-care providers are overburdened and reimbursement rates are skewed. Studies have shown that in some expansion states, Medicaid patients experience longer wait times and reduced access to specialists compared with non-expansion states.

States have also faced immense budgetary challenges, with Medicaid often consuming an increasing share of state budgets, incentivizing them to rely on funding gimmicks. With federal debt continuing to rise, it’s not a matter of if but when the enhanced federal support phases out. If this happens abruptly as part of a federal budget crisis, expansion states will be forced to make drastic cuts without adequate time to prepare.

The ten remaining principled states have wisely avoided this budgetary time bomb. Instead of being lured by temporary federal funds, they have maintained their focus on Medicaid’s core mission. Preserving the fiscal health of these states means resisting the temptation to expand Medicaid under flawed financial assumptions.

House Republicans recently unveiled their plans for Medicaid as part of the “big, beautiful bill.” Unfortunately, the proposal falls short of addressing key concerns that conservatives have about the program. It locks in the state funding gimmick known as the provider tax at current levels and does not start work requirements until after the end of Trump’s term. More important, it fails to address this flawed federal match rate that continues to pressure states to expand.

The problem seems obvious, so why are federal policymakers hesitant to fix it? One reason is the fear of political fallout from coverage loss headlines. Last week’s report from the Congressional Budget Office (CBO), requested by congressional Democrats, sheds light on the reality, and it’s not as dire as some feared.

The CBO analysis examined five policy options to reduce federal Medicaid spending. Among these, reducing the $9 federal taxpayer contribution for every $1 spent by states, known as the Federal Medical Assistance Percentage (FMAP), for the Medicaid expansion population to match traditional enrollees was shown to result in the least coverage loss.

The CBO concluded that this approach is less harmful because it allows states to maintain coverage discretion. Unlike other options, such as per-enrollee spending caps that mandate automatic funding cuts, reducing the FMAP gives states the flexibility to absorb some costs or find other ways to continue supporting the expansion population.

The moral argument for reform is clear. Current incentives push states to spend on healthy, able-bodied adults rather than the sick and disabled. This has led to approximately 700,000 disabled people being placed on Medicaid waiting lists for essential services like home health care. Additionally, some states pay providers higher reimbursement rates for healthy Medicaid enrollees than they do for Medicare patients, exacerbating inequities. Addressing these disparities is not just a policy choice, it is a moral imperative.

Fortunately, a strong contingent of Republicans in Congress represents principled states that have not expanded: 87 House members and 17 senators. Republicans from these principled states should band together to ensure that their states’ long-standing commitment to responsible Medicaid policy is upheld.

For over a decade, these states have resisted the pressure to expand, maintaining a steadfast commitment to prioritizing vulnerable populations. The White House should also recognize the value of standing strong for these states, which supported President Trump in all three of his presidential elections (2016, 2020, 2024), except for Wisconsin in 2020.

Republicans in Congress must remember whom they represent. They must stand firm against pressure to force Medicaid expansion on states that have made a principled decision to prioritize the vulnerable. The road to universal Medicaid is not inevitable. If the last holdouts are fortified, the nation can preserve Medicaid’s original purpose.