Which states expanded Medicaid after 2024 and how did that affect eligibility through 2026?
Executive summary
A handful of states implemented Medicaid expansion after 2023 — notably North Carolina’s December 2023 launch led to more than 600,000 enrollees by December 16, 2024 [1]. Available sources do not provide a comprehensive list of every state that adopted expansion after 2024, nor a single authoritative catalog of expansion actions through 2026; reporting and trackers cited here focus on trends, incentives, and policy changes affecting eligibility through 2026 [2] [3] [4].
1. What we can verify: recent, concrete expansions and enrollment
North Carolina signed and implemented Medicaid expansion effective Dec. 1, 2023 and reported more than 600,000 people enrolled in the first year of implementation, a rapid uptake state officials highlighted on Dec. 16, 2024 [1]. The Urban Institute and related analyses treat North Carolina (and South Dakota earlier) as expansion states for 2024 modeling, showing that adding remaining non‑expansion states in 2024 would have materially increased coverage nationally [2] [5].
2. How many states remained non‑expansion in 2024–25 — and the coverage gap
Multiple policy organizations continued to identify roughly 10 states that had not adopted the ACA’s 138% FPL adult expansion as of 2023–2024; Urban Institute and RWJF lists name these ten: Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming [2] [6]. That long-standing list frames analyses of potential coverage gains if those states expanded [2] [5].
3. Eligibility rules tied to expansion: who gained access through 2024–2026
Where states adopted the ACA adult expansion, adults ages 19–64 with incomes up to about 138% of the federal poverty level became eligible for Medicaid — the normal expansion approach used in most states [7] [8]. Analyses assume expansion raises eligibility to roughly 138% FPL (for example, $20,783 individual / $43,056 family of four in 2024 figures cited by state analyses) and that expansion populations are covered by an enhanced federal match [8] [5].
4. Policy headwinds and federal changes shaping eligibility by 2026
Federal legislation and regulatory changes enacted in 2025 (often called H.R.1 / the One Big Beautiful Bill Act in sources) introduced new work and verification requirements and reduced some incentives, which states must interpret and implement through 2026–2028; these federal changes affect how expansion eligibility is administered and therefore practical access even where expansion exists [4] [9] [10]. KFF and other analysts warned these changes could reduce enrollment or raise administrative barriers starting as early as 2026 [11] [9].
5. Diverging state approaches and strings attached to “expansion”
States have tailored expansion: most simply raised income limits to 138% FPL, but some approved expansions with additional conditions — for example, Georgia’s program has work requirements tied to its expansion and states like Kansas have proposed work or reporting conditions in legislative proposals [8] [12]. The presence of state-level work rules, verification regimes, or waivers means “expansion” does not guarantee identical eligibility or ease of enrollment across states [8] [12].
6. What the analyses predict about coverage and state budgets through 2026
Research cited by CBPP and the Urban Institute concluded expansion generally increases coverage and can be fiscally manageable for states — Urban estimated 2.3 million would gain coverage if the remaining ten expanded in 2024, and other work suggested the ten remaining states expanding in 2024 would raise federal spending materially while producing state economic and hospital stability benefits [2] [3] [5]. KFF and trade analyses expected Medicaid enrollment to flatten in FY2026 as unwinding effects end, with expansion policy tweaks and federal changes exerting upward and downward pressures [11].
7. Limits of available reporting and what’s not found here
Available sources in this packet do not provide a definitive, up‑to‑the‑minute roster of every state that adopted expansion after 2024 nor do they list each state’s exact implementation date through 2026; trackers like KFF and state press releases are the usual primary sources for that granular chronology [2] [1]. For precise, state‑by‑state adoption dates after 2024 and the detailed text of any state‑specific conditions in effect through 2026, consult state Medicaid agencies and the KFF expansion tracker [1] [2].
8. Bottom line for residents and policymakers
Where states expanded, adults up to roughly 138% FPL became eligible and enrollment rose (North Carolina is a clear recent example with 600,000 newly enrolled in year one) [1] [8]. But federal policy changes in 2025 introduced new work and verification requirements and altered incentives, meaning the practical reach of expansion and enrollment stability in 2026 depended on how each state implemented or resisted those federal rules [4] [9].