Editor’s Note: This piece is a counterpoint to an article written by Rick Cohen, Not Expanding Medicaid Leaves 5 Million in Health Coverage Gap


The Kaiser Family Foundationreleased a study on the effect of 26 states electing not to expand Medicaid coverage to all individuals up to 138 percent of the poverty level, as authorized by the Affordable Care Act (ACA). The Medicaid expansion was designed to be mandatory, with the federal government picking up all the cost for the first few years, and then tapering down to a permanent 90-percent federal share. (The 90 percent federal share of Medicaid expansion contrasts with the roughly 60 percent federal share for Medicaid recipients not part of the expansion group.)

The U.S. Supreme Court, in its decisions upholding the constitutionality of the ACA, held that the federal government could not withhold all Medicaid funds from states refusing to adopt the expansion program. Instead, the federal government must make participation by states in Medicaid expansion voluntary.

Kaiser has been working to identify where and who would be affected by decisions not to expand coverage. Out of 17 million people intended to be covered, about one-third, or 5.1 million, live in states that have not yet adopted Medicaid expansion. About half of the five million live in just five states: Texas, Florida, Georgia, Ohio, and North Carolina.

Much has been made of the political composition of the 26 states. All have Republican governors and/or GOP-controlled state legislatures. Healthcare reform has been a polarizing issue in the U.S. for decades. The ACA passed Congress in March 2010 without a single Republican vote in support and with virtually no GOP proposals incorporated into the final bill. The failure to achieve a bipartisan reform and the protracted preparation for implementation have done no favors to the concept, either. However, the states