Expanded Medicaid is a provision of the Affordable Care Act that allows states to extend Medicaid health coverage to nearly all adults earning up to 138% of the federal poverty level, roughly $21,597 a year for an individual or $44,367 for a family of four in 2025. Before expansion, most states limited Medicaid to specific groups like pregnant women, children, people with disabilities, and very low-income parents, leaving millions of working-age adults without coverage regardless of how little they earned. As of 2025, 41 states (including Washington, D.C.) have adopted the expansion, while 10 have not.
Who Qualifies Under Expanded Medicaid
The key change is simplicity. In expansion states, you can qualify based on income alone. If your household income falls below 138% of the federal poverty level, you’re eligible, period. Your age (between 18 and 65), whether you have children, and your health status don’t factor into the decision. That’s a sharp departure from traditional Medicaid, which required applicants to fit into a defined category on top of meeting income limits.
For context, here’s what 138% of the federal poverty level looks like in dollar terms for 2025 in the 48 contiguous states:
- Single adult: $21,597 per year
- Family of four: $44,367 per year
These thresholds are slightly higher in Alaska and Hawaii. If your income is above 138% FPL, you generally transition to marketplace insurance plans with subsidies instead.
The Coverage Gap in Non-Expansion States
In the 10 states that haven’t expanded Medicaid, a strange problem exists. Traditional Medicaid in those states often covers only parents earning well below the poverty line, sometimes less than half of it. Meanwhile, marketplace insurance subsidies only kick in at 100% of the poverty level. That leaves a group of people, often working adults without dependent children, who earn too much for their state’s Medicaid program but too little to qualify for marketplace help. This is known as the coverage gap.
The states that have not adopted expansion are Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming. These are predominantly in the South, and they contain a disproportionate share of the country’s uninsured population. In Texas alone, the gap affects hundreds of thousands of residents whose income falls below the poverty line but who don’t qualify for either program.
Some of these states have active political movements pushing for change. In Florida, an organizing committee relaunched an initiative in early 2026 aiming to put Medicaid expansion on the 2028 ballot. South Dakota, which already expanded Medicaid, has a 2026 ballot measure that would create a trigger allowing the state to end expansion if the federal government reduces its share of funding below 90%.
How Expansion Is Funded
One of the central features of Medicaid expansion is the enhanced federal funding rate. For the traditional Medicaid population, the federal government covers a share of costs that varies by state, typically between 50% and 77%. For the expansion population, the federal match started at 100% when expansion launched in 2014 and gradually stepped down to 90%, where it has remained. That means states pay just 10 cents of every dollar spent covering the expansion group.
This funding structure was designed to make expansion financially attractive to states. Even so, political opposition in some states has centered on concerns about the remaining 10% cost share and the possibility that the federal government could reduce its contribution in the future.
How States Customize Expansion
Not every expansion state runs the program identically. Federal law allows states to apply for Section 1115 waivers, which let them test modifications that wouldn’t normally be permitted under standard Medicaid rules. Some states have used these waivers to require small monthly premiums from expansion enrollees, create health savings account structures, offer incentives for healthy behaviors like completing wellness visits, or impose graduated copayments for non-emergency use of emergency rooms.
These waivers mean the experience of being on expanded Medicaid can vary significantly depending on where you live. In some states it functions almost identically to traditional Medicaid. In others, it looks more like a hybrid between Medicaid and private insurance, with cost-sharing responsibilities that wouldn’t exist in a standard program.
Impact on Preventive Care
Expanding Medicaid coverage has measurably increased the use of preventive health services. Research tracking trends from before and after expansion found that lower-income residents in expansion states saw meaningful gains in colon cancer screening and HIV testing compared to their counterparts in non-expansion states. By 2019, colon cancer screening rose by about 2.5 percentage points and HIV testing by about 2.4 percentage points among this group, both statistically significant differences.
Higher-income residents in expansion states also showed gains in preventive services, with increases in colon cancer screening, HIV testing, and flu vaccination. The pattern suggests that expansion didn’t just help the newly insured: it may have contributed to broader shifts in how healthcare systems deliver preventive care in those states.
Impact on Hospitals and Uncompensated Care
Hospitals in expansion states saw a dramatic reduction in the cost of treating uninsured patients. Before expansion took effect, hospitals in those states averaged about 12 uncompensated care days per bed each year. By 2014, the first year of full expansion, that figure dropped roughly 34%, to about 7.9 days per bed. Hospitals specifically designated to serve large numbers of low-income patients saw a similar 35% drop.
In non-expansion states, hospitals saw almost no change over the same period, going from 12.8 to 12.3 uncompensated care days per bed. That gap illustrates one of the less visible consequences of not expanding: hospitals in those states continue absorbing the cost of treating uninsured patients, which can strain budgets and threaten the viability of rural facilities in particular.
How to Check Your Eligibility
If you live in an expansion state, you can apply for Medicaid through your state’s Medicaid agency or through HealthCare.gov. The application process primarily revolves around verifying your income and residency. Because expansion eligibility is income-based rather than category-based, the process is generally more straightforward than traditional Medicaid applications, which sometimes required documentation of disability, pregnancy, or other qualifying conditions.
If you live in a non-expansion state and your income is below the poverty line, your options are more limited. You may still qualify for traditional Medicaid if you fall into a covered category (such as being a parent of young children, pregnant, or having a qualifying disability), but if you fall into the coverage gap, neither Medicaid nor marketplace subsidies will be available to you under current law.