The signing of North Carolina's Medicaid expansion bill leaves 10 states that have not expanded the program under the ACA — but the holdouts are unlikely to make a change anytime soon, The Washington Post reported March 28.
Some states have expanded Medicaid through ballot measures approved by voters. This most recently occurred in South Dakota in November. Three of the remaining holdout states have citizen-led ballot measure processes — Florida, Wyoming and Mississippi — but that path seems viable only in Florida, according to the report.
Expansion advocates are eying the fall 2026 election, but state law requires the support of 60 percent of voters for passage, according to the Post. Only expansion in Idaho has eclipsed that figure.
Advocates are watching Alabama, where the governor has the power to expand Medicaid without the state Legislature's approval. A spokesperson for Gov. Kay Ivey told the Post the governor remains concerned how the state will pay for it long term.
Kansas Gov. Laura Kelly has for years unsuccessfully pushed for expansion amid legislative opposition, according to the report. Her chief of staff said an uphill battle remains, but if a deal can be reached with the House speaker, the Senate may come around.
Georgia is moving forward with a limited expansion with work requirements. That program is set to begin July 1.
The other states that have not expanded Medicaid under the ACA are South Carolina, Tennessee, Texas and Wisconsin.