Ten states have not expanded Medicaid under the Affordable Care Act: Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming. The remaining 40 states plus Washington, D.C. have adopted the expansion, which extends Medicaid coverage to most adults earning up to 138% of the federal poverty level (about $20,800 per year for an individual in 2024).
The Full List of Non-Expansion States
- Alabama
- Florida
- Georgia
- Kansas
- Mississippi
- South Carolina
- Tennessee
- Texas
- Wisconsin
- Wyoming
All ten are led by Republican governors or have Republican-controlled legislatures that have blocked expansion efforts. Several, including Texas and Florida, are among the most populous states in the country, meaning the policy decision affects millions of residents.
Who Qualifies for Medicaid in These States
In expansion states, any adult earning under 138% of the federal poverty level qualifies for Medicaid. In non-expansion states, the eligibility rules are far more restrictive, and in most cases, adults without children don’t qualify at all regardless of income.
Even parents with dependent children face extremely low income cutoffs. Texas sets its eligibility threshold at just 12% of the federal poverty level, roughly $3,600 a year for a family of three. Alabama’s cutoff is 13%. Florida allows parents to earn up to 24%, and Georgia up to 28%. The most generous of the non-expansion states are Wisconsin at 95% and Tennessee at 84%, but even those fall well short of the 138% standard in expansion states.
To put that in practical terms: a parent in Texas working 20 hours a week at minimum wage already earns too much to qualify for Medicaid, yet earns too little to afford private insurance.
The Coverage Gap
The mismatch between state Medicaid limits and federal marketplace subsidies creates what’s known as the “coverage gap.” People in this gap earn too much for their state’s Medicaid program but too little to qualify for subsidized insurance on the ACA marketplace, which generally starts at 100% of the poverty level. In expansion states, this gap doesn’t exist because Medicaid catches everyone below 138% of the poverty level.
The coverage gap is unique to non-expansion states. If you live in one of these ten states, earn between your state’s Medicaid cutoff and 100% of the poverty level, and aren’t pregnant, disabled, or elderly, you likely have no affordable path to health insurance. This affects a disproportionate number of Black and Hispanic adults, since several of the non-expansion states have large populations of color and high poverty rates.
Georgia’s Partial Approach
Georgia stands out as the only non-expansion state that has created its own limited alternative. The state’s Pathways to Coverage program extends Medicaid to some low-income adults, but with a significant catch: enrollees must complete at least 80 hours per month of “qualifying activities.” These include employment, job training, vocational education, community service, or being a parent of a child under six. College students can count their credit hours toward the requirement.
This work requirement model is far more restrictive than standard Medicaid expansion, and enrollment has been modest compared to what full expansion would cover. No other non-expansion state has implemented a similar program.
Impact on Hospitals and Rural Communities
When hospitals treat uninsured patients who can’t pay, that cost becomes “bad debt” or charity care, and the hospital absorbs the loss. In non-expansion states, where uninsured rates are higher, rural hospitals are especially vulnerable. Research from the Medicaid and CHIP Payment and Access Commission found that Medicaid expansion is associated with stronger hospital finances and a lower likelihood of closure, particularly in rural areas that previously had many uninsured adults.
Rural hospital closures have accelerated in recent years, and the pattern skews heavily toward non-expansion states. When a rural hospital closes, residents may need to drive an hour or more for emergency care, lab work, or labor and delivery services.
Maternal Health Consequences
The stakes extend to life-and-death outcomes for new mothers. Research from Georgetown University found that Medicaid expansion is associated with seven fewer maternal deaths per 100,000 live births compared to non-expansion states. The reductions were largest among Black and Hispanic women, populations that already face higher maternal mortality rates. Several of the non-expansion states, particularly Mississippi, Alabama, and Georgia, consistently rank among the worst in the nation for maternal health outcomes.
Why These States Haven’t Expanded
The federal government covers 90% of the cost of Medicaid expansion, with states responsible for just 10%. To sweeten the deal further, the American Rescue Plan Act offered holdout states a temporary 5 percentage point increase in their existing federal matching rate for two years if they adopted expansion. For most of the remaining states, this would have meant the federal government actually paid them more in total Medicaid funding than expansion would cost, at least in the short term.
Despite the financial incentives, opposition in these states is largely ideological. Republican lawmakers have argued that expansion grows government dependency, that the federal government could reduce its funding commitment in the future, and that states should have more control over how they structure their safety-net programs. In several states, including Kansas and Mississippi, governors have vetoed or blocked expansion bills that had bipartisan legislative support.
Wisconsin’s Unusual Position
Wisconsin occupies a unique spot on this list. While it has not formally adopted the ACA’s Medicaid expansion, it covers parents up to 95% of the federal poverty level and extends some Medicaid coverage to childless adults, something most other non-expansion states do not do. The practical gap between Wisconsin’s program and full expansion is smaller than in states like Texas or Alabama, but the state still misses the higher federal matching rate that comes with official expansion.