A Playbook for Implementing Medicaid Expansion: Louisiana’s Experience

Perspective State Health Policy US Health Care Reform

Policy Points:

  • Twelve states have yet to expand Medicaid under the Affordable Care Act (ACA). Louisiana offers a model of steps that states and counties can take to rapidly enroll eligible persons while balancing eligibility integrity and doing so within a limited administrative budget.
  • In a post-COVID-19 health care landscape, Medicaid expansion can improve and protect population health and boost state economies, even amid budget shortfalls.
  • Even though Louisiana compares well with other states in eligibility and enrollment efforts, future expansions may integrate other social support programs into their implementation strategies.

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.


Boles W, Kennedy R, Siewert E, Rowland D, Lyons B, Gee RK. A Playbook for Implementing Medicaid Expansion: Louisiana's Experience. Milbank Q. October 11, 2021. https://doi.org/10.1111/1468-0009.12540