With Donald Trump returning to the White House and Republicans taking full control of Congress in 2025, the Affordable Care Act's Medicaid expansion is once again on the brink.
More than 3 million adults in nine states would immediately be at risk of losing health insurance if Republicans cut the additional federal Medicaid funding that allows states to expand eligibility. According to KFFa health information nonprofit that includes KFF Health News and Georgetown University Center for Children and Families. That's because states have trigger laws that quickly end Medicaid expansion if federal funding declines.
The states are Arizona, Arkansas, Illinois, Indiana, Montana, New Hampshire, North Carolina, Utah, and Virginia.
The Affordable Care Act of 2010 encouraged states to expand their Medicaid programs to cover more low-income Americans who don't have health insurance through work. Forty states and the District of Columbia agreed, expanding health insurance to an estimated 21 million people since 2014 and helping push the U.S. uninsured rate to record lows.
In return, the federal government will pay 90% of the cost to cover population growth. This is much higher than the federal rate for other Medicaid recipients, which averages about 57% nationally.
Conservative policy groups, which have generally opposed the ACA, argue that the program is too expensive and covers too many people. Democrats argue that Medicaid expansion saves lives and communities by expanding coverage to people who can't afford private insurance.
If Congress cuts federal funding, state legislatures will be forced to make up the difference, putting Medicaid expansion in jeopardy in all states that have agreed to Medicaid (even those without trigger laws) said Renuka Tipirneni, an associate professor at New York University. Michigan School of Public Health.
Tipirneni said the decision to maintain or reduce expansion “depends on politics at the state level.”
For example, Michigan approved the trigger as part of its Medicaid expansion in 2013, but at the time it was led by a Republican governor and legislature. Last year, with the government under Democratic control, the state eliminated the funding trigger.
Six of the nine states with trigger laws (Arizona, Arkansas, Indiana, Montana, North Carolina, and Utah) supported Trump in the 2024 election.
In most of the nine states, it is triggered when federal funding falls below the 90% threshold. Under Arizona's move, the expansion would be terminated if the funding rate falls below 80%.
Montana law allows the expansion to be scaled back if funding falls below 90%, but allows it to continue if lawmakers identify additional funding. Under state law, Montana legislators Medicaid expansion must be reauthorized Expansion will end by 2025.
Researchers at KFF and the Georgetown Center estimate that 3.1 million to 3.7 million people across the state would immediately lose coverage when the trigger occurs. The difference depends on how states treat people who were added to Medicaid before the ACA expansion. Even if the expansion ends, you may still be eligible.
Three other states (Iowa, Idaho, and New Mexico) have laws that require governments to reduce the fiscal impact of losing federal Medicaid expansion funds, but do not automatically end expansion. do not have. Including these three states would put about 4.3 million Medicaid expansion enrollees at risk of losing coverage, according to KFF.
The ACA authorized the expansion of Medicaid to adults with incomes up to 138% of the federal poverty level, or about $20,783 per individual, in 2024.
Of the 81 million people enrolled in Medicaid nationwide, nearly a quarter are enrolled in the program through the expansion.
“The decline in expansion match rates will likely require significant increases in state spending, so all states will likely need to consider whether to continue expansion coverage,” said Robin, Vice President and Medicaid Program Director.・Mr. Ludowitz stated. and KFF uninsured. “If states end coverage, the number of uninsured people will likely increase and access to health care will be limited across red and blue states that have adopted expansions.”
Once a social program such as Medicaid is granted, states rarely terminate eligibility.
Edwin Park, a research professor at Georgetown University's Center for Children and Families, said the trigger makes it politically easier to halt Medicaid expansion because state lawmakers don't have to take new steps to reduce coverage. He said it would be.
To understand the impact of trigger laws, consider what happened after the Supreme Court struck down Roe v. Wade and the resulting constitutional right to abortion in 2022. Conservative lawmakers in 13 states had developed trigger bills that would automatically implement the ban if the state's right to abortion was taken away. These state laws caused the restrictions to go into effect immediately or shortly after the court's decision.
States adopted the trigger as part of Medicaid expansion to win support from lawmakers skeptical of funneling state money to a federal program unpopular with most Republicans.
It's unclear what President Trump and Congressional Republicans will do about Medicaid after taking office in January, but one possible indicator is that the influential conservative policy group led by former Trump health adviser Brian Blades, That would be a recent recommendation from Paragon Health Research Institute.
Paragon is proposing that the federal government phase out the 90% federal match due to expansion starting in 2026, making it equivalent to each state's federal match for traditional registrants until 2034. Under this plan, states would still have access to ACA Medicaid expansion funds, but would be able to limit coverage to enrollees with incomes up to the federal poverty level. Currently, to receive expansion funding, states must guarantee everyone up to 138% of the poverty level.
Daniel Dirksen, director of the University of Arizona Center for Rural Health, said it's unlikely Arizona will move to eliminate that trigger and make up for lost federal funding. “It would be difficult to sell at this point because it would put a huge strain on the budget,” he said.
Medicaid has been a target of Republicans in Washington before. Republican Congressional leaders in 2017 proposed a bill to cut federal expansion funding, which would shift billions of dollars in costs to states. This plan was part of the Obamacare repeal strategy, but ultimately failed.
KFF Health News is a national newsroom that produces in-depth journalism on health issues and is one of KFF's core operating programs and an independent source of health policy research, polling, and journalism. Click here for details KFF.Subscribe Join KFF Health News for free morning briefings.
this article It first appeared KFF Health News Republished here under a Creative Commons license.
