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UNITED STATES ROADMAP

ROADMAP POLICIES AND STRATEGIES

EFFECTIVE POLICIES

EFFECTIVE STRATEGIES

EMERGING STRATEGIES

NEWLY INTERACTIVE
THE POLICY IMPACT CALCULATOR
Methods and Sources
FAQ
Additional Roadmap Resources

EXPANDED INCOME ELIGIBILITY FOR HEALTH INSURANCE

States can employ several strategies to increase health insurance coverage for their residents, and the most widely studied strategy is the expansion of Medicaid eligibility. Medicaid is a joint federal and state program that provides health insurance to low-income households, covering one in five Americans and 41% of all live births in the United States.1,2

The federal Patient Protection and Affordable Care Act, also known as the ACA, was signed into law in 2010. In addition to providing subsidies to purchase health insurance in the online Marketplace, the ACA expanded Medicaid eligibility for most adults with incomes at or below 138% of the federal poverty level (FPL), to begin in 2014. In 2012, the Supreme Court ruled3 that the federal expansion was unconstitutional, which allowed states to determine their own income guidelines and eligibility criteria.4

For states that have expanded Medicaid, the federal government currently covers 90% of the state’s Medicaid costs for the expansion population.5 States are responsible for paying the remaining 10% using general revenue, alcohol taxes, tobacco taxes, provider taxes, and other dedicated revenue and government contributions.6,7

As an incentive for nonexpansion states to expand Medicaid, the American Rescue Plan Act of 2021 (ARPA) offered an additional 5 percentage point increase to the federal government’s share of a state’s Medicaid costs (the Federal Medical Assistance Percentage, or FMAP). The increase was available to states on a permanent basis for 2 years after new expansion, no matter when the expansion occurred; however, the federal reconciliation bill passed in July 2025 removed this incentive program.8,9

Because Medicaid Income Eligibility Varies Widely Across States, Many Individuals Lack Coverage

The populations most affected by a state’s decision to expand Medicaid are previously ineligible childless adults, including childless women of reproductive age,10 and parents whose incomes fall between the pre-ACA income guidelines established in their state and 138% of the FPL. States that have not expanded Medicaid do not cover most childless, nonelderly adults,11 regardless of income level.12 Income eligibility thresholds for parents range from a low of 15% of the FPL in Texas to 105% of the FPL in Tennessee.

In most states, Medicaid income eligibility thresholds are higher for pregnant individuals than other adults. As of September 2025, through options initially included in ARPA and made permanent in the 2023 Consolidated Appropriations Act (CAA), all states except Arkansas and Wisconsin have moved to extend pregnancy Medicaid coverage from 60 days to 12 months postpartum through either state plan amendments, Section 1115 waivers, or enacted legislation.13

When eligibility for pregnancy Medicaid coverage ends, the recipient must switch to traditional parent Medicaid or use a subsidy to purchase health coverage on the Marketplace. In nonexpansion states, many new parents lose health insurance coverage after the postpartum period because their incomes are too high for traditional Medicaid, but not high enough to receive subsidies on the Marketplace (100% of the FPL).

Expanding Medicaid Eligibility Allows More People to Access Necessary Care

In nonexpansion states, many parents with low incomes still earn too much to qualify for Medicaid, and most childless adults are not eligible regardless of their income. Many of these adults may also earn too little to afford private health insurance. Approximately 1.4 million uninsured adults would become newly eligible for Medicaid if the remaining nonexpansion states raised their income eligibility thresholds to 138% of the FPL.14 Workers with low incomes in these states, including many child care teachers, would be likely recipients of Medicaid coverage.15

Medicaid Expansion Can Help People Initiate Health Care Prior to Conception, a Critical First Step for Healthy Pregnancies and Births

Without expanded Medicaid eligibility, childless adults with low incomes may have limited access to family planning services, preventative care before conception, and prenatal care in the earliest stages of pregnancy. Access to health insurance in these important periods may lead to lower rates of maternal mortality and adverse birth outcomes, including infant mortality, low birthweight, and preterm birth.16

Expanding Medicaid Helps Keep Families Financially Stable

Families who have access to free or low-cost health services through Medicaid are less likely to be severely burdened by medical costs and less likely to incur medical debt, which may free up resources for other household necessities.17,18,19 Further, individuals who previously avoided medical care due to high costs are more likely to seek out needed health services, which can lead to improved physical and mental health outcomes.20,21

Search the Prenatal-to-3 Policy Clearinghouse for an ongoing inventory of rigorous evidence reviews, including more information on expanded income eligibility for health insurance.

Various studies have shown Medicaid expansion can help families access needed care and services, increase household resources, improve healthy and equitable birth outcomes, and improve child health and development. Medicaid expansion also increases rates of coverage, increases the length of coverage before and after pregnancy, decreases uninsurance rates, and increases the probability of timely and adequate prenatal care.

Medicaid expansion also bolsters families’ economic security by reducing out-of-pocket medical spending and limiting the accumulation of medical debt. Furthermore, Medicaid expansion has been found to decrease family poverty rates, housing instability, and avoidance of health care due to cost barriers. Additional studies have found positive effects on healthy birth outcomes including lower rates of preterm birth, low birthweight, and maternal mortality. Benefits for child health and development include decreased rates of child neglect.

Medicaid Expansion Reduces Racial Disparities in Insurance Coverage, But More Research Is Needed to Understand the Full Potential of Medicaid Expansion to Reduce Disparities in Outcomes

Families of color are less likely to have access to affordable health insurance coverage.22 Medicaid expansion decreases uninsurance rates among Hispanic and multiracial women,23 increases Medicaid coverage rates among Hispanic and Black women,24 and increases the receipt of prenatal care among Hispanic women.25 These positive outcomes have a stronger effect size relative to outcomes observed for White women, which may reduce disparities across racial and ethnic groups.

Evidence also suggests that Medicaid expansion contributes to better birth outcomes, including reductions in maternal mortality rates for some women of color.26,27 More research is needed, however, to determine whether these improvements translate into narrower overall disparities in outcomes. Some studies show that Medicaid expansion reduces disparities in infant mortality between Hispanic28 and White infants,29 as well as disparities in preterm birth and very low birthweight between Black and White infants.30 Despite these positive findings, other studies find no evidence that Medicaid expansion reduces disparities in birth outcomes.31,32,33,34,35

Evidence does show, however, that the impact of Medicaid expansion on outcomes related to family financial stability, such as child support receipt, was more beneficial for people with higher educational levels and who identified as White.36 These results are important because they point to possibly exacerbated inequality rather than equity. More research is needed to understand the full potential of Medicaid expansion to reduce disparities beyond access to health insurance.

For more information on what we know and what we still need to learn about Medicaid expansion, see the evidence review on expanded income eligibility for health insurance.

Throughout the summer of 2025, Congress debated and ultimately enacted H.R. 1, a budget reconciliation bill that will influence how states fund their Medicaid programs and what policy options they have for implementing Medicaid expansion.

The bill is projected to reduce federal Medicaid spending by more than $1 trillion over the next decade. States could see a 6% to 21% reduction in federal Medicaid funding compared to the levels they have received over the past decade.37 The bill also restricts how states can raise revenue to finance their share of Medicaid costs. Specifically, the bill introduces new restrictions on provider taxes – a funding mechanism used by all states except Alaska.38 These significant reductions could force states to scale back their Medicaid programs over time.  

The reconciliation bill also narrows states’ flexibility in implementing Medicaid expansion. By the end of 2026, states will be required to impose work requirements as a condition of Medicaid eligibility for adults in the expansion population, with exceptions for parents of children under age 14.39 States will no longer be able to waive work requirements through Section 1115 waivers. Additionally, by October 2028, states will be required to impose cost sharing requirements (such as co-pays for non-primary care services) for adults with incomes between 100% and 138% of the FPL. Previously, states had the ability to do so, but it was not required.39

The bill also repeals the incentive of a 5 percentage point boost in the Federal Medical Assistance Percentage (FMAP), or federal share of Medicaid costs, over 2 years for states newly implementing Medicaid expansion.39 North Carolina is the only state to have used this option and therefore will not be impacted, but no other states will be eligible for the boost moving forward.

Additional bill provisions add barriers to coverage, including more frequent eligibility redetermination requirements for the expansion population and the removal of eligibility and enrollment rules issued under the Biden administration to address administrative burdens.39

Although not ultimately included in the final legislation, Congress considered other major changes around the FMAP. Proposals included reducing the FMAP for the expansion population or lowering it specifically in states that extend coverage to individuals who would otherwise be eligible if not for their immigration status.39 More than a dozen states have trigger laws that would have required them to either repeal Medicaid expansion or modify their programs if such FMAP reductions had been enacted.

Implications of Medicaid Funding for Other State Programs and Policies

The reconciliation bill’s reductions in federal Medicaid spending and new restrictions on state financing will not only shape states’ Medicaid expansion decisions – they will also likely affect several other critical prenatal-to-3 policies and programs that rely on Medicaid dollars. Cuts in federal support could constrain states’ ability to sustain or expand programs that serve infants, toddlers, and their families, including group prenatal care, Early Intervention services, community-based doulas, evidence-based home visiting programs, and comprehensive screening and connection programs. As of September 2025, it remains unclear how, when, or to what extent the new federal parameters will directly influence funding for these programs.

For more information on the state policy levers that are influenced by federal Medicaid funding, see our profiles on Group Prenatal Care, Early Intervention Services, Community-Based Doulas, Evidence-Based Home Visiting Programs, and Comprehensive Screening and Connection Programs.

As of September 2025, 41 states, including the District of Columbia, have adopted and fully implemented Medicaid expansion under the ACA. One of these states, Montana, enacted legislation this year to prevent its program from expiring on June 30, 2025. However, no states enacted or newly implemented Medicaid expansion in the last year.

Montana Took Action to Prevent its Medicaid Expansion Program from Expiring

Without legislative action, Montana’s Medicaid expansion program was set to expire on June 30, 2025. Legislators faced a similar dilemma in 2019, when the program was also at risk of ending mid-year. This year, similar to 2019, a bill was enacted to continue Medicaid expansion, this time coupled with the introduction of work requirements. Montana legislators also chose to remove the program’s statutory termination date, ensuring that the state will not have to reauthorize Medicaid expansion in the future.

Among Nonexpansion States, 6 Introduced Legislation to Expand Medicaid

Of the 10 states that have not yet fully implemented Medicaid expansion under the ACA, six (Georgia, Kansas, Mississippi, South Carolina, Tennessee, and Texas) considered but did not pass legislation to adopt the policy in the past year. Wisconsin considered legislation to extend postpartum Medicaid coverage but did not consider full ACA expansion. After several states made unprecedented bipartisan progress on expansion legislation in 2024, momentum slowed in 2025. No bills to expand Medicaid advanced out of committee in the most recent state legislative session.

Most of the legislation introduced across the six nonexpansion states would have expanded Medicaid under the ACA by enrolling the expansion population in traditional Medicaid. Other proposals would have enrolled part of the population in traditional Medicaid and permitted adults with incomes between 100% and 138% of the FPL to obtain premium coverage through the marketplace. Texas legislators introduced both of those variations among their 23 bills and proposed expansions targeting specific subsets of the expansion population, such as young adults, women of reproductive age, individuals with a mental health diagnosis, or adults with dependents.

Although Tennessee did not introduce any bills to expand Medicaid directly, state legislators filed legislation that would have authorized the governor to expand Medicaid under the ACA and negotiate the terms with CMS. Tennessee is one of five nonexpansion states that have enacted laws limiting how expansion of Medicaid can be adopted. Tennessee, along with Alabama, Georgia, and Kansas, require legislative approval to implement expansion. Wisconsin prohibits the governor from expanding Medicaid without some involvement of the legislature.

4 States Introduced Legislation to Trigger the Roll-Back of Medicaid Expansion if Federal Matching Rates Decrease

The federal government currently covers 90% of the costs for the Medicaid expansion population through what is known as the Federal Medical Assistance Percentage (FMAP). In contrast, the standard FMAP for traditional Medicaid enrollees (those eligible before expansion) varies by state but typically covers 50% to 76% of costs.40 If the FMAP for the expansion population were to decrease, states would be responsible for a significantly larger share of program costs. Because of this risk, 12 states previously enacted ‘trigger laws,’ which are laws that would automatically end Medicaid expansion or require coverage changes if the FMAP for the expansion population were to decrease.

As the federal government discussed potential changes to the FMAP, four states (Arizona, Idaho, South Dakota, and West Virginia) introduced legislation to establish or strengthen corresponding Medicaid expansion trigger laws. Of these, only South Dakota enacted such legislation, passing a joint resolution to place a measure about the FMAP on the next general election ballot. If approved by voters, the measure would repeal South Dakota’s Medicaid expansion program upon reduction of the FMAP.

West Virginia introduced legislation to discontinue Medicaid expansion if the FMAP for the expansion population fell below 90%. Idaho, which already requires the state to take action to mitigate the fiscal impact of an FMAP reduction, proposed a full repeal of Medicaid expansion if the FMAP drops. Arizona introduced legislation to amend its existing trigger law so that expansion would be repealed if the rate fell below 90%, as opposed to the current threshold of 80%.

Conversely, North Carolina, which has an existing trigger law to repeal Medicaid expansion, introduced legislation to adjust its trigger law, so that Medicaid expansion would only be discontinued if the FMAP fell below 80%, down from 90%. Legislators also introduced a separate bill to eliminate the trigger entirely. Neither bill passed during this session.

For more information on the state policy levers to help maximize the effectiveness of policies that improve access to perinatal health insurance, including Medicaid expansion, see our State Policy Lever Checklists.

States Continued to Pursue Federal Waivers to Implement Work Requirements, with Potential to Limit Access to Medicaid Coverage

In 2025, 11 Medicaid expansion states (Arizona, Connecticut, Idaho, Indiana, Iowa, Kentucky, Missouri, Montana, New Hampshire, New York, and North Carolina) introduced legislation directing their state Medicaid programs to seek Section 1115 waivers related to work requirements. Additionally, legislators in one nonexpansion state, Kansas, included work requirements in a bill to expand Medicaid eligibility; however, that bill ultimately did not pass.

In five of the expansion states (Idaho, Indiana, Iowa, Kentucky, and Montana), bills were enacted to implement work requirements. Legislators in Idaho, Indiana, and Iowa enacted legislation requiring their state to seek federal approval for work requirements for the expansion population. In Kentucky, legislators overrode Governor Beshear’s veto to enact legislation directing the state to submit a waiver applying work requirements to all able-bodied adults enrolled in Medicaid. Montana also included work requirements as part of its legislation to reauthorize the state’s Medicaid expansion program. As of September 2025, Iowa submitted an amendment request to incorporate work requirements for its able-bodied adult expansion population. That request was still under federal review.

Similarly, South Dakota released a new proposed waiver to impose work requirements on adults in the expansion population. The state crafted the waiver following voter approval of a 2024 ballot referendum allowing the state to impose work requirements in the Medicaid program.

Under the first Trump administration, 13 states received CMS approval to add work requirements to their Medicaid programs through Section 1115 waivers (Arizona, Arkansas, Georgia, Indiana, Kentucky, Maine, Michigan, Nebraska, New Hampshire, Ohio, South Carolina, Utah, and Wisconsin). Only Arkansas implemented penalties for noncompliance with work reporting before those requirements were overturned by a federal judge in April of 2019. Arkansas submitted a new Section 1115 waiver request in early 2024 seeking renewed federal approval of its Medicaid program with work requirements.

In 2023, following litigation, Georgia became the only state with an active Medicaid work reporting requirement. The state’s partial Medicaid expansion program, Pathways to Coverage, only covers individuals with incomes up to 100% of the FPL and requires enrollees to work 80 hours per month, submit monthly documentation, and does not allow exemptions for caregiving responsibilities. As a result of these requirements, far fewer individuals than are eligible based on income alone enrolled in the program. In its first 18 months, Pathways to Coverage enrolled approximately 7,400 individuals, which is less than a third of the state’s estimated enrollment of 25,000 in the first year.41

Although states continued to pursue Section 1115 waivers for work requirements in the last year, a new federal baseline was established when Congress enacted H.R. 1 in July 2025. Beginning in 2027, the law will require individuals enrolled in Medicaid through the ACA expansion population to complete at least 80 hours per month of work or other qualifying activities to maintain program eligibility, with limited exemptions. The law sets a uniform national standard for the 80-hour threshold, and no state has proposed a higher requirement through previous waivers. States may not waive this requirement but may request delayed implementation under certain conditions. States also cannot apply work requirements to populations excluded under federal law – such as parents of young children – without obtaining federal approval through a waiver.

States do, however, retain the ability to enforce the policy in more restrictive ways, such as requiring more frequent verification of work hours, applying longer “look-back” periods at application and redetermination, shortening grace periods for noncompliance, or imposing additional documentation requirements.42 As a result, implementation is likely to vary considerably across states, with some adopting the minimum standard and others layering more complex administrative processes that could increase coverage losses.

State Legislatures Worked to Limit State Agency Authority over Medicaid

In addition to legislation on work requirements and federal matching rates, four states (Arkansas, Idaho, Kansas, and Kentucky) introduced bills to limit the ability of state agencies to apply for waivers without legislative approval. Idaho, Kansas, and Kentucky enacted legislation that prohibits state Medicaid agencies from seeking amendments or waivers that impact program eligibility, benefits, or net costs to the state without explicit legislative direction. In both Kansas and Kentucky, these bills were enacted by legislative override after governor vetoes. Arkansas introduced similar legislation that would have restricted the state Medicaid agency’s authority and required both gubernatorial and legislative approval of any amendments or waivers. The bill in Arkansas, however, did not pass.

States Added Additional Administrative Barriers to Accessing Medicaid

Regressive state action was not limited to work requirements and limiting state agency authority to implement waivers. In Indiana, the legislation to establish work requirements also included a provision to limit the state Medicaid agency’s functions outside of waiver submission. The enacted legislation prohibits state agencies or contractors working with the Medicaid program from advertising or marketing Medicaid coverage. The bill also prohibits the state from accepting self-attestations, or an individual’s own verification of their information, without additional external verifications, and places limits on the use of presumptive eligibility for Medicaid.

Several other states introduced similar restrictions on self-attestation, enrollment, and renewal processes. Louisiana enacted legislation which prohibits the state agency from relying on ex parte, or automatic, renewals for Medicaid redeterminations except where required by federal law. The bill also prohibits the state from accepting self-attestations without additional documentation.

Alabama also sought to prohibit reliance on self-attestations without data verification, and Texas and Pennsylvania introduced bills to limit the use of ex parte renewals. Finally, Wisconsin and Pennsylvania sought to prohibit the use of prepopulated forms for Medicaid renewals. Among these actions, Louisiana was the only state to enact such a bill during this session.

10 Expansion States Introduced Legislation to Provide Medicaid or CHIP Coverage to New Populations Beyond the Expansion Population

Of the 41 expansion states, five states (California, Colorado, the District of Columbia, Oregon, and Washington) have already implemented more generous policies that extend coverage beyond what is required under the ACA. Each of these states offers eligibility to most adults with low incomes who were previously ineligible due to immigration status. The District of Columbia also extends coverage to childless adults with incomes at or below 215% of the FPL. In Colorado, a previously enacted policy expanding coverage to children and pregnant individuals regardless of immigration status took effect in January 2025.

Ten more states (Delaware, Hawaii, Illinois, Kansas, Minnesota, New Mexico, New York, Rhode Island, Vermont, and West Virginia) sought to expand their eligibility criteria this year. Legislators in seven of those expansion states (Illinois, Minnesota, New Mexico, New York, Rhode Island, Vermont, and West Virginia) introduced bills in the last year to expand Medicaid eligibility to additional income levels and demographic groups. In Illinois, legislation was introduced to expand eligibility to foreign-born victims of human trafficking.

Legislators in Minnesota, New Mexico, Vermont, and West Virginia sought to expand Medicaid to additional income levels and create programs for those with higher incomes to buy in to the program. In New York, a bill was introduced to cover individuals who would otherwise be eligible if not for their immigration status, and legislators in Rhode Island attempted to extend coverage to individuals during the start and end of incarceration. Conversely, in Oregon, legislation was introduced to rescind coverage for those adults currently eligible under the state’s immigration-based eligibility expansion. None of these bills were enacted this session.

Legislators in three states (Delaware, Hawaii, and Kansas) attempted to expand eligibility for their state’s Children’s Health Insurance Program (CHIP). In Delaware, legislation was introduced to explore options for extending CHIP to individuals otherwise ineligible due to immigration status. Hawaii legislators proposed appropriating funds for a similar expansion in coverage. Alternatively, legislators in Kansas introduced a bill to raise CHIP income eligibility to 250% of the FPL. None of these bills passed this session.

2 States Began Implementing 12 Months of Postpartum Coverage, and the Only 2 States Not to Have Adopted the Extension Introduced Legislation to Do So

Before passage of the American Rescue Plan Act (ARPA), Medicaid coverage for pregnant individuals typically ended 60 days postpartum. ARPA created a temporary state option which allowed states to extend pregnancy-related Medicaid coverage to 12 months postpartum through state plan amendments in addition to the previously used avenues. The 2023 Consolidated Appropriations Act made this option permanent. For states that provide postpartum coverage through CHIP, the extension must also apply to CHIP enrollees.

Since the option to extend postpartum coverage via state plan amendment took effect, nearly all states have implemented the policy and extended pregnancy Medicaid coverage to 12 months postpartum. As of September 2025, 49 states across both expansion and nonexpansion categories have adopted and implemented the policy. Idaho and Iowa were the most recent states to receive CMS approval and began implementation in January 2025.

Only Arkansas and Wisconsin have not adopted the 12-month postpartum Medicaid extension. However, legislators in both states introduced bills to do so in the last year. Arkansas’ bill passed the House but did not receive a hearing in the Senate. Wisconsin’s proposal also passed one chamber, but had not moved in the House as of September 2025. Wisconsin previously adopted a policy to extend postpartum coverage to 90 days, but the state has not yet received CMS approval for the change.

States Have Taken Steps to Provide Continuity of Coverage for Children

To promote stability and prevent gaps in coverage, the 2023 CAA required all states to provide 12-month continuous health insurance eligibility for children. As states work to implement this requirement, several have gone further by seeking CMS approval for multi-year continuous coverage for children enrolled in Medicaid.

As of September 2025, nine states have begun implementing multi-year continuous Medicaid eligibility for children either from birth to age 3 or birth to age 6. Six of these states (Colorado, Hawaii, Minnesota, New York, North Carolina, and Pennsylvania) launched their programs in the last year after their waivers were approved in November or December 2024. New Mexico, Oregon, and Washington received approval in earlier years and had already begun implementation.

California, Illinois, and Ohio are in the process of developing similar policies. Though the Ohio budget bill included a provision to halt development of the state’s multi-year continuous coverage program, the governor ultimately vetoed that measure, thereby preserving the efforts currently being pursued through a pending Section 1115 waiver. Legislators in five additional states (Alaska, Maine, Montana, Rhode Island, and Texas) introduced legislation to adopt multi-year continuous eligibility in 2025, but none of those bills were enacted this session.

In July 2025, CMS announced its intention to reject all state proposals seeking to either adopt new or extend existing Section 1115 waivers related to multi-year continuous eligibility moving forward.43 Of the nine states with active Section 1115 policies, Colorado’s waiver is the earliest set to expire in December 2025, with the rest scheduled to phase out by 2029.44 This CMS policy shift is likely to affect the aforementioned eight states (Alaska, California, Illinois, Ohio, Maine, Montana, Rhode Island, and Texas) that have been considering steps toward multi-year continuous eligibility, as federal approval for new programs of this type will no longer be available.

For more information on each state’s progress on expanding Medicaid, find our individual state summaries under Additional Resources below (and here).

In Nonexpansion States, Most Childless Adults and Many Low-Income Parents Are Not Eligible for Medicaid Coverage

Most childless adults are not eligible for coverage through Medicaid in nonexpansion states. Georgia and Wisconsin are two exceptions, as both provide coverage to childless adults with incomes at or below 100% of the FPL ($15,650 annually). Georgia’s program, however, has a work requirement which substantially limits eligibility. In contrast, childless adults with incomes at or below 138% of the FPL ($21,597 annually) are eligible for Medicaid in expansion states. The District of Columbia is even more generous than other expansion states and grants coverage to childless adults with incomes at or below 215% of the FPL ($33,647.50 annually).

For parents with low incomes in nonexpansion states, income eligibility varies from as low as 15% of the FPL in Texas ($3,997.50 annually for a family of three) to up to 105% of the FPL in Tennessee ($27,982.50). In expansion states, parents with incomes at or below 138% of the FPL are eligible ($26,650 annually for a family of three). Again, the District of Columbia sets even more generous income guidelines than other expansion states, covering parents with incomes up to 221% of the FPL ($58,896.50).

In Most States, Regardless of Expansion Status, Income Eligibility Guidelines Are Typically Higher for Pregnant Individuals

Medicaid income eligibility thresholds for pregnant individuals are generally set higher than those for childless adults or parents, regardless of the state’s expansion status. However, the income eligibility thresholds vary considerably across states.

In 27 states, the income eligibility threshold for pregnant individuals is at least 200% of the FPL ($31,300 annually for one individual). In three of these states (the District of Columbia, Iowa, and Wisconsin), the threshold is greater than 300% of the FPL ($46,950 annually). Iowa has the most generous threshold for pregnant individuals, at 380% of the FPL ($59,470 annually).

The three states with the lowest income eligibility threshold (Idaho, Louisiana, and South Dakota) set the threshold for pregnant individuals at only 138% of the FPL ($21,597 annually), which is also the standard for parents in those states.

Lack of Health Insurance Prevents Women of Childbearing Age from Accessing Health Care That Can Lead to Healthier Perinatal Outcomes and Stronger Financial Security

Access to health insurance allows women of childbearing age to seek affordable medical care prior to pregnancy and begin prenatal care earlier once pregnant. Each of these behaviors is linked to healthier birth outcomes. In every state, the percentage of women of childbearing age with low incomes (defined as incomes at or below 138% of the FPL) who lack health insurance indicates the proportion of women in that state who could be supported by expanded eligibility and access to Medicaid.

Currently, the District of Columbia, Hawaii, Massachusetts, Rhode Island, and Vermont have the highest rates of health coverage for income-eligible women; in each of these states, less than 7% of income-eligible women are uninsured. Texas, conversely, has the highest uninsurance rate, with 40.7% of income-eligible women in the state lacking health insurance. Nationally, approximately one in five (18.9%) income-eligible women is uninsured.

Click here to view the compiled 2025 Roadmap expanded income eligibility for health insurance progress summaries for all 50 states and the District of Columbia.

View our Policy Impact Calculator, which illustrates how policies, such as state minimum wage, paid family and medical leave, out-of-pocket child care expenses, taxes and tax credits, as well as federal nutrition benefits, interact to impact overall household resources.

  1. KFF. (n.d.) State Health facts: Births financed by Medicaid, 2023. KFF. https://www.kff.org/medicaid/state-indicator/births-financed-by-medicaid/
  2. Rudowitz, R., Burns, A., Hinton, E., & Mohamed, M. (2023, June 30). 10 things to know about Medicaid. KFF. https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-medicaid/
  3. National Federation of Independent Business et al. v. Sebelius, Secretary of Health and Human Services, et al. (US Supreme Court, 2012). US 11-393. https://www.law.cornell.edu/supct/pdf/11-393.pdf
  4. Perkins, J. (2012, July). Fact sheet: The Supreme Court’s ACA decision and its implications for Medicaid. National Health Law Program. https://healthlaw.org/resource/fact-sheet-the-supreme-courts-aca-decision-its-implications-for-medicaid/
  5. Rudowitz, R., Corallo, B., & Garfield, R. (2021, March 17). New incentive for states to adopt the ACA Medicaid expansion: Implications for state spending. KFF. https://www.kff.org/medicaid/issue-brief/new-incentive-for-states-to-adopt-the-aca-medicaid-expansion-implications-for-state-spending/
  6. Park, E. (2021, March 18). Medicaid learning lab. Session 2: Medicaid and CHIP financing. Georgetown University Health Policy Institute: CCF. https://ccf.georgetown.edu/2021/02/05/medicaid-learning-lab/
  7. Hayes, S.L., Coleman, A., Collins, S.R. & Nuzum, R. (2019). The fiscal case for Medicaid expansion. The Commonwealth Fund. https://www.commonwealthfund.org/blog/2019/fiscal-case-medicaid-expansion
  8. Park, E. (2021, March 18). Medicaid learning lab. Session 2: Medicaid and CHIP financing. Georgetown University Health Policy Institute: CCF. https://ccf.georgetown.edu/2021/02/05/medicaid-learning-lab/
  9. Park, E., & Corlette, S. (2021, March). American Rescue Plan Act: Health care provisions explained. Georgetown University Health Policy Institute: CCF. https://ccf.georgetown.edu/wp-content/uploads/2021/03/American-Rescue-Plan-signed-fix-2.pdf
  10. Reproductive age is defined as ages 15 to 44; state Medicaid expansion covers adults ages 19 to 64.
  11. Georgia and Wisconsin are two exceptions, which both provide coverage for adults with incomes at or below 100 percent of the FPL.
  12. To see the range of Medicaid eligibility requirements during the perinatal period, see the evidence review on expanded income eligibility for health insurance.
  13. KFF. (2025, January 17). Medicaid postpartum coverage extension tracker. KFF. https://www.kff.org/medicaid/issue-brief/medicaid-postpartum-coverage-extension-tracker/
  14. Drake, P., Tolbert, J., Rudowitz, R., & Damico, A. (2025, February 25). How many uninsured are in the coverage gap and how many could be eligible if all states adopted the Medicaid Expansion? https://www.kff.org/medicaid/issue-brief/how-many-uninsured-are-in-the-coverage-gap-and-how-many-could-be-eligible-if-all-states-adopted-the-medicaid-expansion/
  15. McLean, C., Austin, L.J.E., Whitebook, M., & Olson, K.L. (2021). Early Childhood Workforce Index – 2020. Berkeley, CA: Center for the Study of Child Care Employment, University of California, Berkeley. Retrieved from https://cscce.berkeley.edu/workforce-index-2020/report-pdf/
  16. Park, E., & Corlette, S. (2021, March). American Rescue Plan Act: Health care provisions explained. Georgetown University Health Policy Institute: CCF. https://ccf.georgetown.edu/wp-content/uploads/2021/03/American-Rescue-Plan-signed-fix-2.pdf
  17. Giled, S., Chakraborty, O., & Russo, T. (2017, August). How Medicaid expansion affected out-of-pocket health care spending for low-income families. The Commonwealth Fund. https://www.commonwealthfund.org/publications/issue-briefs/2017/aug/how-medicaid-expansion-affected-out-pocket-health-care-spending
  18. Kuroki, M. (2020). The effect of health insurance coverage on personal bankruptcy: Evidence from the Medicaid expansion. Review of Economics of the Household, 00, 1-23. doi:10.1007/s11150-020-09492-0
  19. Callison, K., Walker, B., Stoecker, C., Self, J., & Diana, M.L. (2021). Medicaid expansion reduced uncompensated care costs at Louisiana hospitals; May be a model for other states. Health Affairs, 40(3), 529–535. doi: 10.1377/hlthaff.2020.01677
  20. Wen, H., Druss, B.G., Cummings, J.R. (2015). Effect of Medicaid expansions on health insurance coverage and access to care among low-income adults with behavioral health conditions. Health Services Research,50(6), 1787–1809
  21. Winkelman, T.N.A & Chang, V.W. (2018). Medicaid expansion, mental health, and access to care among childless adults with and without chronic conditions. Journal of General Internal Medicine, 33(3), 376–383.
  22. Garfield, R., Orgera, K., & Damico, A. (2021, January 21). The coverage gap: Uninsured poor adults in states that do not expand Medicaid. KFF. https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/
  23. Johnston, E.M., McMorrow S, Thomas, T.W., & Kenney, G.M. (2020). ACA Medicaid expansion and insurance coverage among new mothers living in poverty. Pediatrics, 145(5), e20193178. DOI: https://doi.org/10.1542/peds.2019-3178 [Expanded Income Eligibility for Health Insurance Evidence Review Study DD]
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  25. Harvey, S. M., Oakley, L.P., Gibbs, S.E., Mahakalanda, S., Luck, J., & Yoon, J. (2021). Impact of Medicaid expansion in Oregon on access to prenatal care. Preventive Medicine, 143, 106360. https://doi.org/10.1016/j.ypmed.2020.106360. Received 17 July 2020; Received in revised form 30 October 2020; [Expanded Income Eligibility for Health Insurance Evidence Review Study EE]
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  27. Eliason, E. L. (2020). Adoption of Medicaid expansion is associated with lower maternal mortality. Women’s Health Issues, 30(3), 147-152. https://doi.org/10.1016/j.whi.2020.01.005 [Expanded Income Eligibility for Health Insurance Evidence Review Study J] 
  28. Wiggins, A., Karaye, I. M., & Horney, J. A. (2020). Medicaid expansion and infant mortality, revisited: A difference-in-differences analysis. Health Services Research, 55(3), 393-398. 6). https://doi.org/10.1111/1475-6773.13286
  29. Cook, A., & Stype, A. (2021). Medicaid expansion and infant mortality: the (questionable) impact of the Affordable Care Act. Journal of Epidemiology and Community Health, 75, 10-15. http://dx.doi.org.ezproxy.lib.utexas.edu/10.1136/jech-2019-213666 [Expanded Income Eligibility for Health Insurance Evidence Review Study GG]
  30. Brown, C. C., Moore, J. E., Felix, H. C., Stewart, M. K., Bird, T. M., Lowery, C. L., & Tilford, J. M. (2019). Association of state Medicaid expansion status with low birth weight and preterm birth. JAMA, 321(16), 1598–1609. https://doi.org/10.1001/jama.2019.3678 [Expanded Income Eligibility for Health Insurance Evidence Review Study A]
  31. Boudreaux, M. H., Dagher, R. K., & Lorch, S. A. (2018). The association of health reform and infant health: Evidence from Massachusetts. Health Services Research, 53(4), 2406–2425. https://doi.org/10.1111/1475-6773.12779 [Expanded Income Eligibility for Health Insurance Evidence Review Study W]
  32. Cook, A., & Stype, A. (2021). Medicaid expansion and infant mortality: the (questionable) impact of the Affordable Care Act. Journal of Epidemiology and Community Health, 75, 10-15. http://dx.doi.org.ezproxy.lib.utexas.edu/10.1136/jech-2019-213666 [Expanded Income Eligibility for Health Insurance Evidence Review Study GG]
  33. Eliason, E. L. (2020). Adoption of Medicaid expansion is associated with lower maternal mortality. Women’s Health Issues, 30(3), 147-152. https://doi.org/10.1016/j.whi.2020.01.005 [Expanded Income Eligibility for Health Insurance Evidence Review Study J]
  34. Strully, K. W., Chatterji, P., Liu, H., Han, S., & Schell, L. (2024). Effects Of Medicaid Expansions on coverage, prenatal care, and health among American Indian/Alaska Native women. Health Affairs, 43(3), 344–353. https://doi.org/10.1377/hlthaff.2023.00672 [Expanded Income Eligibility for Health Insurance Evidence Review Study ZZ]
  35. Sagili, M., & Bayindir, E. E. (2024). Association of Medicaid expansion with birth outcomes: Evidence from a natural experiment in Texas. BMC Public Health, 24(1), 1486. https://doi.org/10.1186/s12889-024-19007-6 [Expanded Income Eligibility for Health Insurance Evidence Review Study AAA]
  36. Bullinger, L.R. (2020). Child support and the Affordable Care Act’s Medicaid expansions. Journal of Policy Analysis and Management, 40(1), 42-77. doi:10.1002/pam.22238 [Expanded Income Eligibility for Health Insurance Evidence Review Study JJ]
  37. Euhus, R., Williams, E., Burns, A., & Rudowitz, R. (2025). Allocating CBO’s estimates of federal Medicaid spending reductions across the states: Senate reconciliation bill. https://www.kff.org/medicaid/issue-brief/allocating-cbos-estimates-of-federal-medicaid-spending-reductions-across-the-states-senate-reconciliation-bill/
  38. Burns, A., Hinton, E., Williams, E., & Rudowitz, R. (2025, March). 5 key facts about Medicaid and provider taxes. KFF. https://www.kff.org/medicaid/5-key-facts-about-medicaid-and-provider-taxes/
  39. KFF. (2025, July). Health provisions in the 2025 federal budget reconciliation bill. KFF. https://www.kff.org/tracking-the-medicaid-provisions-in-the-2025-budget-bill/
  40. Congressional Research Service. (2025, April). Medicaid’s Federal Medical Assistance Percentage (FMAP).S. Congress. https://www.congress.gov/crs_external_products/R/PDF/R43847/R43847.13.pdf
  41. Hinton, E. & Rudowitz, R. (2025, May). Implementing work requirements on a national scale: What we know from state waiver experience. https://www.kff.org/policy-watch/implementing-work-requirements-on-a-national-scale-what-we-know-from-state-waiver-experience/
  42. Hinton, E., Diana, A., & Rudowitzm R. (2025, July). A closer look at the work requirement provisions in the 2025 federal budget reconciliation law. https://www.kff.org/medicaid/a-closer-look-at-the-work-requirement-provisions-in-the-2025-federal-budget-reconciliation-law/
  43. Snyder, D. (2025, July). Section 1115 Demonstration authority for continuous eligibility initiatives. S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. https://www.medicaid.gov/resources-for-states/downloads/contin-elig-ltr-to-states.pdf
  44. Diana, A. (2025, July). State waivers for continuous Medicaid eligibility to end under CMS guidance. https://www.kff.org/quick-take/state-waivers-for-continuous-medicaid-eligibility-to-end-under-cms-guidance/
  45.  

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