Which states have not expanded Medicaid and how does that affect low-income residents?
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Executive summary
As of 2025, ten states have not adopted the Affordable Care Act’s Medicaid expansion, leaving roughly 1.4–1.6 million people in the “coverage gap” who are ineligible for both Medicaid and marketplace subsidies (KFF estimates 1.4 million; Stateline reported 1.6 million) [1] [2]. Research comparing expansion and non‑expansion states shows expansion increased coverage and access and reduced forgoing care among low‑income adults; nonexpansion states still have much lower income eligibility for nondisabled adults — in some cases effectively $0 — which deepens the access gap [3] [4].
1. Where the holdouts stand: the ten states that haven’t expanded
Multiple trackers and reporting note that 41 states plus DC had expanded Medicaid by early 2025, leaving ten states that had not adopted the ACA expansion; KFF’s state tracker and contemporary reporting frame the number consistently at ten non‑expansion states as of 2025 [1] [5]. News coverage over several years has treated this group as the remaining “holdouts,” and some states border between partial reforms or limited programs and full expansion [6] [7].
2. Who falls into the “coverage gap” and how many people are affected
KFF estimates about 1.4 million uninsured people in the ten non‑expansion states fall into the coverage gap — adults with incomes below the threshold for marketplace tax credits and above the states’ often very low Medicaid limits (KFF calculates 138% FPL as the ACA expansion threshold) [1]. Stateline reported a similar figure of about 1.6 million people in 2024, underscoring consistent estimates across reporting [2]. These are disproportionately working adults, people of color, and people with disabilities, according to KFF [1].
3. The practical consequences for low‑income residents
Where states have expanded, adults with income up to roughly 138% of the federal poverty level qualify for Medicaid based on income alone; in non‑expansion states adults without dependent children often face extremely tight or zero income eligibility, meaning many low‑income adults cannot access Medicaid and are also ineligible for marketplace subsidies — creating the coverage gap [8] [4]. Empirical comparisons show expansion states saw increased insurance coverage, reduced avoidance of care for cost reasons, and higher use of preventive services among populations who would otherwise be in the gap [3].
4. Financial and health‑system ripple effects for states
Analysts and reporting tie non‑expansion to worse outcomes for rural hospitals and state health metrics: holdout states have accounted for a disproportionate share of rural hospital closures and poorer access indicators, according to the American Hospital Association cited in reporting on holdouts [6]. Separately, research warns that cutting or rolling back federal support for expansion would shift costs to states and could cause millions to lose coverage — a reminder that expansion decisions have large budget and access implications [9].
5. Policy workarounds, temporary fixes, and political dynamics
Policy proposals have included fully subsidized marketplace coverage for the poorest residents of non‑expansion states as a temporary federal fallback; advocates and think tanks framed such approaches as a practical way to reach those in the gap, though some measures were time‑limited or contingent on broader federal action [10]. Politically, some holdout states have flirted with partial expansions, work requirements, or targeted programs; others have seen voter initiatives or legislative debates move towards expansion — signaling political heterogeneity among the ten holdouts [2] [6].
6. Competing viewpoints and implicit agendas in the coverage debate
Proponents of expansion point to improved coverage, access, and some mortality benefits demonstrated in research; opponents often cite fiscal concerns, potential for federal budget changes, and arguments for state control or targeted programs. Advocacy groups on both sides shape the narrative: for example, right‑leaning groups have promoted tighter eligibility and work requirement policies while progressive groups push for full expansion or federally provided alternatives [11] [9]. Reporters note that some state lawmakers emphasize budgetary tradeoffs while business groups in some states support expansion to reduce uncompensated care costs [2] [12].
7. What reporting doesn’t resolve and key limitations
Available sources document the number of holdout states and the estimated size of the coverage gap, and they assess access and system impacts; they do not list the ten specific states in a single provided excerpt here, nor do they provide exhaustive, up‑to‑the‑minute names and legislative changes for each state in these snippets — readers should consult KFF’s live expansion tracker or state budget documents for a current, state‑by‑state list and the latest legislative actions [5] [1]. The empirical literature finds strong access effects but sparser, more mixed evidence on long‑term health outcomes [3].
8. Bottom line for low‑income residents
Low‑income adults in non‑expansion states face materially higher barriers to health coverage: many earn too little to qualify for marketplace subsidies yet are ineligible for Medicaid under restrictive state rules, producing a measurable “coverage gap” that leaves an estimated 1.4–1.6 million people uninsured and more likely to delay or forgo care [1] [2] [3]. Policymaking choices at the state and federal level — from expansion votes to subsidy experiments or cuts to federal support — will determine whether that gap closes or widens [10] [9].