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March 2022 (Volume 100)
Quarterly Article
Will Boles
Ruth Kennedy
Emma Siewert
Diane Rowland
Barbara Lyons
Rebekah E. Gee
Sep 23, 2026
Sep 14, 2026
Sep 9, 2026
Back to The Milbank Quarterly
Policy Points:
The passage of the Patient Protection and Affordable Care Act (ACA) in 2010 enabled transformative change in state Medicaid programs. The ACA included modernization requirements, such as transitioning income eligibility calculations to the modified adjusted gross income (MAGI) methodology and integrating data infrastructure for effective enrollment.1 States also gained the option to expand Medicaid eligibility to all citizens at or below 138% of the federal poverty level (FPL), as well as to provide coverage to lower-income adults without dependent children. Medicaid expansion has proved to be beneficial for states, decreasing mortality rates, increasing rates of primary care access, improving financial security for members, decreasing statewide uninsured rates, preventing the closures of rural hospitals, improving state economies, and increasing state general fund savings for state budgets.2-7 Despite these benefits, only 38 states have expanded, with many state policymakers continuing to debate whether to adopt the expansion.8
Both the federal government and other states have suggested strategies for implementing Medicaid expansion. After the Centers for Medicare & Medicaid Services (CMS) issued guidance for the states in 2011,9 the US Government Accountability Office (GAO) conducted a survey of state Medicaid and budgetary officials in 2012 to identify state roles, responsibilities, and actions in regard to expanding Medicaid.1 The GAO found that states face considerable administrative hurdles and fiscal concerns in implementing Medicaid expansion, including managing Medicaid enrollment, acquiring or modifying information technology systems to support Medicaid, and enrolling previously eligible but not enrolled individuals in Medicaid.
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