Medicaid Expansion

Medicaid Expansion by State & Month, 2014 - 2022

Back in January, as the 2023 Open Enrollment Period wound down, I posted a colorful graph which tracked ACA Qualified Health Plan (QHP) enrollment over ten years of Open Enrollment Periods.

Today I'm doing the same thing for ACA Medicaid Expansion. The data comes from the Centers for Medicare & Medicaid Services monthly Medicaid Budget & Expenditure System reports.

Unfortunately the MBES reports only run through September 2022; my best guess is that the national total as of March 2023 was up to around 24.4 million or so, roughly 900K higher than what's shown below.

Also keep in mind that if the remaining 10 states had expanded Medicaid under the ACA by now, the grand total would have been up to 3.5 million higher (around 27.9 million nationally).

Aside from various holdout states jumping in as the years have passed, the most notable milestone was the month that the COVID pandemic hit the U.S. in full force, shutting businesses down across the country in March 2020.

No further analysis or comment here; I just think this is a pretty cool graphic...and keep in mind that most of the ~23.5 million people represented here (again, likely over 24M today) would have been utterly screwed without the Affordable Care Act being in place when the pandemic hit. Click the image for a higher-resolution version; the states are listed on the right-hand side, though they might be difficult to make out:

Back in January, I noted that total enrollment in healthcare policies either specifically created by or expanded to more people by the Affordable Care Act had broken 40 million Americans:

With last week's report from the Centers for Medicare & Medicaid Services (CMS) touting the record-breaking 16.3 million Qualified Health Plan (QHP) selections during the 2023 Open Enrollment Period (OEP), it's time to take another look at the grand total.

For this, I'm assuming a similar 94% average effectuation rate as of February 1st (2 days from now) to the ASPE report from last year for QHP enrollees. Taken literally, that would mean 15,328,061 effectuated on-exchange ACA enrollees.


Back in late January, I crunched the numbers on the total number of Americans who currently have healthcare coverage directly via the Affordable Care Act. This includes three categories: Exchange-based Qualified Health Plans (QHPs); the Basic Health Plan (BHP) progams in Minnesota and New York; and Medicaid Expansion in the 38 states (+DC) which had implemented it as of that point.

I concluded that the total numbers for each were roughly 15.4 million QHPs, 1.2 million BHPs and 23.5 million Medicaid expansion enrollees, or around 40.1 million people total.

Earlier this week, the Centers for Medicare & Medicaid Services (CMS) confirmed my estimates and even came in slightly higher, at around 40.2 million. They put effectuated QHPs at 15.6 million and Medicaid expansion enrollment at around 23.4 million.

A few weeks ago I raised an alarm about the federal budget introduced by former Trump Administration OMB Director Russell Vought's think tank, which is being embraced by many House Republicans as their blueprint for a formal budget proposal.

As I noted at the time, Vought's proposed budget would include, among many other horrific things, completely eliminating funding for the ACA's Medicaid expansion program as well as complete elimination of all Advance Premium Tax Credit (APTC) funding for ACA exchange-based individual market enrollees.

I went on to note that if this proposal were to somehow pass the Senate and be signed into law by President Biden (neither of which is likely to happen, to put it mildly), nearly 40 million Americans would lose healthcare coverage as a result nationally.

Below, I've broken that number out by state to give better context about just how draconian such an eventuality would be.

UPDATE 3/15/23: The agreed-to Medicaid expansion deal has passed the NC State Senate! It now just needs to pass the state House one final time and then it's on to Gov. Cooper's desk to be signed into law!

UPDATE 3/22/23: The bill has now passed the state House by a stunning 94-22 margin as well! It still has to pass one more time tomorrow (a "concurrence" vote) and then it's on to Gov. Cooper's desk!

UPDATE 3/23/23: On the 13th Anniversary of the Affordable Care Act, the North Carolina House has officially taken the final vote needed for passage, with the bill easily passing 87 - 24. It's now onto Gov. Cooper, who has vowed to sign it into law ASAP.

North Carolina

While ACA Medicaid expansion just died for a 9th time in Wyoming, it may finally be on the verge of actually happening in a much larger state. Via Gary Robertson of the Associated Press:

RALEIGH, N.C. (AP) — The North Carolina General Assembly began on Tuesday what could become the final push to expand Medicaid to hundreds of thousands of low-income adults in the state with a House measure that quickly advanced through two committees with bipartisan support.

The bill is generally expected to pass the NC House as soon as today...and a different version of the bill is expected to pass the state Senate as well. The issue is the difference between the two versions:


Back in December, the state with the smallest population in the country, Wyoming, looked like it might finally carry the ACA Medicaid expansion football into the end zone:

‘Let’s just get this done’: Wyoming Legislature to consider Medicaid expansion again in 2023

Medicaid expansion will be up for debate once again when the Wyoming Legislature convenes for its 67th session in January.

The legislature’s Joint Revenue Committee voted to advance the Medical Treatment Opportunity Act to the legislative session during a meeting this month.

It’s the same bill the legislature considered during the 2022 session, state staffers said.

The proposed legislation would allow Medicaid expansion to occur in Wyoming as long as the federal contribution to the program remains at 90 percent or higher.

Last spring, I noted that total enrollment in healthcare policies either specifically created by or expanded to more people by the Affordable Care Act had broken 36 million Americans:

The press release talks about "more than 35 million" being enrolled, but when you look at the actual data, it's almost certainly over 36 million as of today. Here's how they break it out:

  • Effectuated ACA exchange enrollment as of March 2022: 13,640,412
  • Medicaid Expansion (newly eligible) as of October 2021: 16,781,800
  • Medicaid Expansion (previously eligible) as of October 2021: 4,261,277
  • Basic Health Plan enrollment as of March 2022: 1,135,190
  • TOTAL: 35,818,679

Notice that even without delving further, the total is already over 35.8 million.

However, there's two important dates to look at here: First, the Medicaid Expansion totals are only up to date as of last October, a good 6 months ago.


With South Dakota becoming the latest holdout state to finally expand Medicaid to adults earning up to 138% of the Federal Poverty Level (FPL) under the Affordable Care Act last month, there's now just 11 states remaining which still haven't done so.

The smallest of these, which is also the smallest state in the country, is Wyoming, which has had a long & storied history when it comes to Medicaid expansion fakeouts. The "Equality State" legislature has considered expanding Medicaid to the roughly 19,000 residents who would become newly eligible for the program eight times since the ACA was signed into law in 2010, only to see approval of it fail at one stage or another every time.

 Well, according to this article by Katie Roenigk at "County 10" in Fremont County, Wyoming, it looks like the 9th time may be the charm:

South Dakotans Decide Healthcare


Back in January 2021, I. noted that:

...over the past few years, the voters of some of those states have decided to take it upon themselves to force their legislators/governors to expand Medicaid anyway, via statewide ballot initiative campaigns: