May 1, 2024

The Medicaid Coverage Gap

According to U.S. Census data, the percentage of people living below the federal poverty level who are uninsured is more than twice as high in states that haven’t expanded Medicaid. Texas, Florida, Georgia and Alabama account for the lion’s share of the coverage gap population and they are among the 10 states where Medicaid expansion is still strongly opposed by the legislature or the governor.

The following states have not yet accepted federal funding to expand Medicaid:

  • Alabama
  • Florida
  • Georgia (partial expansion in mid-2023, with a work requirement)
  • Kansas
  • Mississippi
  • South Carolina (no coverage for parents of minor children)
  • Tennessee (very little coverage gap for parents of minor children)
  • Texas
  • Wisconsin (no coverage gap)
  • Wyoming

Expansion in North Carolina

Although these 10 states have so far refused, Medicaid expansion is becoming harder to resist. Republicans in North Carolina helped their state expand Medicaid in December. Now roughly 600,000 low-income North Carolinians are eligible for coverage.

The narrative around the North Carolina expansion originally suffered a branding problem. For many Republicans, “Medicaid expansion” is still a toxic phrase tied closely to former President Barack Obama, so some states have attempted to put their own spin on the program. Framing the opportunity as “closing the coverage gap” instead of “expanding Medicaid” eventually made expansion palatable.

GOP power brokers suggest their colleagues in Mississippi, Alabama and Georgia might be open to join them. North Carolina Republican Rep. Donny Lambeth recently assured Georgia lawmakers that none of his GOP colleagues lost a primary over their support for expansion.

Delayed Expansion in Georgia

In rural Georgia, nine hospitals have closed since 2010 and free clinics have struggled to fill the void. Because of this, Georgia Republicans were interested in arguments that Medicaid expansion as an economic agent would allow struggling hospitals to remain open to serve the uninsured, low-income in their area while employing a highly-skilled workforce.

Expansion in Georgia would cover roughly 400,000 people, but this expansion has been delayed.

“Pathways to Coverage” in Georgia

Many Republicans have come to acknowledge the coverage gap. But partial solutions like Pathways to Coverage™, promoted by Georgia Governor Brian Kemp, created a more limited expansion with a work requirement. This program has barely gotten off the ground and only enrolled 2,300 people of the 100,000 promised at almost five times the cost.

After signaling an openness to exploring expansion this year, top Republicans in Georgia last Tuesday unveiled a bill tabling expansion for a future session. The bill focuses on reforming hospital regulations–often discussed as a component of a potential deal on Medicaid expansion–that sets up another study committee.

Meanwhile, Georgia is leaving billions of dollars in federal money on the table, and serves as an interesting example of ongoing delays in Medicaid expansion generally, with Republican majorities still reticent to do a full expansion of state Medicaid eligibilities despite ongoing gaps in coverage.

The Politics of Medicaid

The politics of Medicaid are intertwined with issues of race, class and political party. The geographic concentration of people who are poor, uninsured and black is reflected in the way district maps are drawn. Often, the legislators from these areas have little ability to shape state policy, particularly in the South.

Medicaid expansion as a reform enshrined in the Affordable Care Act has become entangled in the politics of each individual state. Thus, each election cycle has the ability to create a turning point in the fight for health equity for all Americans. The role of advocates in these non-expansion states has never been more important. The 2024 elections will shape the future of their citizens’ health care for years to come.

If you would like to help in joining the calls for Medicaid expansion in your state, please contact the Public Policy department by emailing

View the latest Policy Update here.