Lorem ipsum dolor sit amet, consectetuer adipiscing elit, sed diam nonummy nibh euismod tincidunt. Learn More

2026 Roadmap 2025 Roadmap 2024 Roadmap 2023 Roadmap 2022 Roadmap 2021 Roadmap 2020 Roadmap
Twitter
Facebook
LinkedIn
Email
PRINT

UNITED STATES ROADMAP

ROADMAP POLICIES AND STRATEGIES

EFFECTIVE POLICIES

EFFECTIVE STRATEGIES

EMERGING STRATEGIES

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 40% 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 One Big Beautiful Bill Act (OBBBA) removed this incentive program in July 2025.8,9

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 2026, through options initially included in ARPA and made permanent in the 2023 Consolidated Appropriations Act (CAA), all states except Arkansas 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, the large difference between pregnancy and parent Medicaid income limits can leave new parents without an affordable coverage option.

For example, a mother in Texas earning $16,230 per year (75% of the FPL) could qualify for Medicaid during pregnancy because the state covers pregnant individuals in a family of two with incomes up to approximately $42,850 annually (198% of the FPL). She could remain covered through 12 months postpartum, but once that coverage ends around her child’s first birthday, her income would be well above Texas’s parent Medicaid eligibility limit of approximately 15% of the FPL and below the 100% FPL threshold for Marketplace subsidies. Her child may remain eligible for Medicaid or CHIP, but she would be left without a publicly subsidized health insurance option.

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 2.4 million uninsured adults would become newly eligible for Medicaid if the remaining 10 nonexpansion states raised their income eligibility thresholds to 138% of the FPL, including some adults who are currently eligible for Marketplace coverage but not enrolled.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.

Emerging research on the impact of Medicaid work requirements indicates that these policies do not increase employment and can reduce rates of Medicaid and health insurance coverage and enrollment.22 Nevertheless, OBBBA requires states to impose work requirements on many adults covered through Medicaid expansion beginning in January 2027, and several states have begun implementing these requirements ahead of the federal deadline. More research is needed to understand the full scope of changes resulting from implementation of federal work requirements.

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.23 Medicaid expansion decreases uninsurance rates among Hispanic and multiracial women,24 increases Medicaid coverage rates among Hispanic and Black women,25 and increases the receipt of prenatal care among Hispanic women.26 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.27,28 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 Hispanic29 and White infants,30 as well as disparities in preterm birth and very low birthweight between Black and White infants.31 Despite these positive findings, other studies find no evidence that Medicaid expansion reduces disparities in birth outcomes.32,33,34,35,36

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.37 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.

In July 2025, Congress enacted the One Big Beautiful Bill Act (OBBBA), which created the most significant changes to Medicaid eligibility, enrollment, and financing in more than a decade. With many of the law’s largest eligibility changes taking effect in late 2026 and early 2027, states have had a relatively short period to prepare for implementation.

Projected to reduce federal Medicaid spending by more than $915 billion between 2025 and 2034, the law is also expected to increase the number of people without health insurance by 7.5 million by 2034.38 The size of the reductions will vary across states based on their Medicaid enrollment and financing structures.

Many of OBBBA’s largest coverage changes will impact adults who receive Medicaid through expansion programs. The expansion population generally includes adults ages 19 to 64 with incomes up to 138% of the FPL who do not qualify for Medicaid through another eligibility category, including childless adults and parents whose incomes exceed their state’s traditional parent Medicaid eligibility limit.

Beginning in January 2027, states must require most adults in the Medicaid expansion population to work or participate in other qualifying activities for at least 80 hours per month to obtain or maintain Medicaid coverage. Parents and caretakers of children age 13 and younger, pregnant and postpartum people, and certain people with disabilities or serious health conditions are exempt.39 States will no longer be able to waive work requirements through Section 1115 waivers.

The implementation of work requirements alone is projected to increase the number of uninsured people by 5.3 million by 2034.40 Coverage losses are expected to extend beyond people who do not meet the work requirement or qualify for an exclusion: early estimates suggest that approximately 2.8 million additional people will lose Medicaid coverage because of the new steps required to demonstrate and verify work or exclusion status.41 For new applicants, states must verify that an individual met the work requirement or was excluded from it for at least the month immediately before applying but may choose to look back for as many as 3 consecutive months. For people already enrolled, states must verify compliance again as part of the eligibility renewal process and may choose to conduct additional checks between renewals.

These requirements are particularly important for families during pregnancy and after birth. Pregnant and postpartum people are excluded from the work requirement, including those who become pregnant while already enrolled through Medicaid expansion. These enrollees can remain in the expansion eligibility group during pregnancy and the postpartum period without becoming subject to the work requirement. Nearly 16% of pregnant Medicaid enrollees nationally (more than 135,000 people) were enrolled through the expansion category at the time of delivery in 2022.42 States will therefore need to accurately identify pregnancy and postpartum status so these enrollees are recognized as excluded from the work requirement, not incorrectly asked to demonstrate compliance, and not at risk of losing coverage.

OBBBA also requires states to check eligibility for expansion adults every 6 months rather than once a year beginning in 2027. The Congressional Budget Office estimates this rule will increase the number of uninsured people by 700,000 by 2034, with 70% expected to lose coverage due to procedural reasons, communication problems, or difficulty navigating reenrollment.43

More frequent renewals mean families will have additional points during the year when they may need to respond to notices or provide information to maintain coverage – and more opportunities for otherwise eligible people to lose coverage for procedural reasons. These requirements can be especially difficult for those managing health conditions or functional limitations, unstable housing, or other circumstances that make it harder to receive notices, gather documentation, and complete renewal paperwork on time.

OBBBA also narrows federally funded Medicaid eligibility for many lawfully present immigrants beginning October 1, 2026. Refugees, asylees, trafficking survivors, and several other groups that previously qualified will generally lose federally funded eligibility. However, states can continue using a longstanding federal option to cover lawfully residing children and pregnant people, and states may use their own funds to maintain health coverage for people who lose federal eligibility.44

OBBBA Makes Medicaid Expansion Less Financially Attractive to States

OBBBA does not repeal Medicaid expansion or reduce the 90% federal matching rate for people covered through the ACA expansion. However, it sunsets the American Rescue Plan Act incentive that provided states newly implementing Medicaid expansion with a 5 percentage point increase in their regular Federal Medical Assistance Percentage (FMAP), or federal share of Medicaid costs, over 2 years.45 States that begin expansion on or after January 1, 2026, can no longer qualify for the incentive. North Carolina, the only state to have used this option, benefited when it began its expansion in December 2023 and received the temporary funding increase through September 2025, before the new cutoff took effect.

Although not ultimately included in the final legislation, Congress considered reducing the 90% federal matching rate for the expansion population through OBBBA. The final law maintained the 90% match, but 13 states still have trigger laws that could end or alter Medicaid expansion if federal funding decreases in the future.

The act also restricts how states can raise revenue to finance their share of Medicaid costs. Specifically, it introduces new restrictions on provider taxes – taxes on health care providers or health plans that states can use to help finance their share of Medicaid spending.46 In July 2026, the federal government proposed additional rules that could further restrict how states can leverage this funding mechanism, which every state but Alaska uses to some degree.47 Together, these financing changes leave states with fewer options for funding their share of Medicaid and could put pressure on state budgets, provider payments, or other parts of Medicaid over time.48

Further, by October 2028, states will also be required to implement some degree of cost sharing for expansion adults with incomes between 100% and 138% of the FPL, up to $35 per service. Primary care, pregnancy-related services, mental health and substance use treatment, and several other services remain protected from the new requirement. Research on Medicaid and other low-income populations finds that cost sharing can increase financial burden and reduce the use of needed care.49

Implications of Medicaid Funding for Other State Programs and Policies

The reductions in federal Medicaid spending and new restrictions on state financing will not only shape decisions about Medicaid expansion. They may also affect states’ ability to sustain or expand other Medicaid-funded services for pregnant people, infants, toddlers, and their families, including several of the evidenced-based strategies in this Roadmap: group prenatal care, Early Intervention services, community-based doulas, evidence-based home visiting programs, and comprehensive screening and connection programs. As states adjust to lower federal funding and new administrative costs, they may face more difficult choices about whether to maintain or expand these services. It is not yet clear how widespread those effects will be or which programs states will prioritize.

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 2026, 41 states, including the District of Columbia, have adopted and fully implemented Medicaid expansion under the ACA. No states enacted or newly implemented Medicaid expansion in the last year.

Among Nonexpansion States, 4 Introduced Legislation to Expand Medicaid

Of the 10 states that have not yet fully implemented Medicaid expansion under the ACA, four (Georgia, Mississippi, Tennessee, and Wisconsin) considered but did not pass legislation to adopt full or near-full expansion in the past year.

Efforts to expand Medicaid across these states took various forms. Georgia legislators introduced proposals to extend eligibility to adults with incomes at or below 138% of the FPL, although one proposal would have conditioned expansion funding on the federal match rate remaining above 90%. Mississippi legislators introduced multiple expansion proposals, including both traditional Medicaid expansion and alternative models that would have used Medicaid funds to subsidize private or employer-sponsored coverage. Wisconsin was the only state to introduce proposals solely focused on adopting full ACA expansion.

In Tennessee, legislators carried over a proposal from 2025 that would have authorized the governor to negotiate an expansion plan with the federal government. The proposal was considered again this year but did not pass. Tennessee is one of four nonexpansion states that have enacted laws limiting how Medicaid expansion can be adopted. Tennessee, Georgia, and Kansas require legislative approval to implement expansion, and Wisconsin prohibits the governor from expanding Medicaid unless the legislature enacts authorizing legislation.

5 States Considered the Long-Term Durability of Medicaid Expansion if Federal Matching Rates Decrease

The federal government 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 – ranges from approximately 50% to 76% of costs depending on the state.50 If the FMAP for the expansion population were to decrease, states would be responsible for a significantly larger share of program costs. Thirteen states have ‘trigger laws’ that would automatically end Medicaid expansion or require the state to modify or reconsider the program if federal funding decreases. Ohio became the most recent state to enact a trigger law when its Fiscal Year 2026-2027 budget took effect in September 2025.

In the last year, five states (Idaho, North Carolina, Oklahoma, South Dakota, and Utah) considered proposals that would affect whether Medicaid expansion would continue in the future. Idaho and South Dakota considered the most direct repeal proposals: Idaho legislators introduced a bill to repeal Medicaid expansion entirely beginning January 1, 2028, and South Dakota legislators introduced a bill that would have asked voters to repeal the state’s constitutional requirement to provide Medicaid expansion. Though neither proposal passed, South Dakota voters will still consider a narrower measure during the November 2026 general election – a ballot measure that would repeal the state’s constitutional requirement to provide Medicaid expansion if the federal matching rate falls below 90%.

Oklahoma legislators considered several proposed ballot measures that would have weakened constitutional protections for the state’s expansion program. One proposal would have asked voters to move Medicaid expansion from the state constitution into statute if the federal matching rate fell below 90%, making it easier for future legislatures to amend or repeal the program. Other proposals would have permitted or required the state to discontinue expansion following a reduction in federal funding. Although versions of these proposals advanced, none passed before the end of the session. Ultimately, no Medicaid expansion question was placed on the 2026 ballot in Oklahoma.

North Carolina introduced legislation to eliminate its trigger law, but it did not pass. Utah was the only state to enact a policy related to its trigger law this year. Utah retained the requirement that expansion end if the federal matching rate falls below 90%, but delayed termination until after the legislature’s next general session and required the state Medicaid agency to develop options for maintaining expansion within projected funding, giving legislators an opportunity to consider those options.

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.

State Legislatures Continued to Limit State Agency Authority over Medicaid

States continued a trend from previous years of seeking greater control over major Medicaid policy decisions. In 2026, at least five states (Iowa, Kentucky, New Hampshire, New Mexico, and Wyoming) enacted legislation limiting the ability of state Medicaid agencies to expand coverage or make certain optional program changes without legislative approval.

Iowa and New Mexico’s bills require legislative approval for future Medicaid eligibility expansions or increased spending. Wyoming’s bill requires approval for optional eligibility expansions and prohibits renewal of its family planning waiver after it expires. Kentucky and New Hampshire enacted narrower restrictions tied to OBBBA implementation, limiting the state Medicaid agency’s ability to seek certain federal exemptions, waivers, or implementation delays without legislative approval.

Though 14 States Considered Targeted Coverage Expansions or Protections, Others Reduced Coverage

Outside of full ACA expansion, at least 14 states considered or enacted measures to extend eligibility, maintain coverage for populations affected by federal changes, or establish state-funded alternatives.

Eight states (California, Connecticut, Hawaii, Massachusetts, Minnesota, New Jersey, New Mexico, and New York) considered or enacted measures to maintain or create state-funded coverage for immigrants or other people at risk of losing Medicaid because of OBBBA. Minnesota enacted legislation preserving state-funded pregnancy and postpartum coverage for certain noncitizens. New Mexico legislators appropriated $40 million to maintain coverage for lawfully present residents who are losing federal eligibility. California, Massachusetts, New Jersey, and New York considered broader state-funded eligibility proposals, and Connecticut and Hawaii considered temporary or bridge coverage for residents affected by OBBBA.

Connecticut, Washington, and West Virginia considered broader coverage programs for residents with incomes above current Medicaid limits. Connecticut proposed a Basic Health Program for residents with incomes up to 200% of the FPL, Washington proposed expanding Medicaid eligibility to 300% of the FPL with federal approval, and West Virginia proposed a state-administered buy-in program with income-based assistance for residents below 200% of the FPL. Oregon and Rhode Island both attempted to extend coverage to individuals transitioning out of incarceration. None of these proposals passed. Kansas did, however, update its CHIP income standard to 250% of the current FPL, and Virginia considered state-funded coverage for uninsured children who were ineligible for Medicaid or CHIP.

Not all state actions expanded access. Through administrative changes, the District of Columbia reduced Medicaid eligibility for parents and childless adults to 138% of the FPL beginning in January 2026 – down from the levels of 221% and 215% of the FPL it had maintained since 2014 for parents and childless adults, respectively. Colorado attempted to preserve the core of its state-funded health coverage for pregnant people and children who are ineligible for Medicaid due to immigration status by limiting access to some long-term services and authorizing a potential enrollment cap on the program. A previously enacted California policy also took effect in January 2026, freezing new full-scope enrollment for most adults who do not meet federal immigration status requirements.

Wisconsin Extended Postpartum Medicaid Coverage to 12 Months

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 (CAA) 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, all but one state has implemented the policy and extended pregnancy Medicaid coverage to 12 months postpartum. Wisconsin enacted its extension in March 2026, and it became effective in June 2026. Arkansas is now the only state that has not adopted the 12-month postpartum extension.

Federal Changes Reduced Momentum for Multi-Year Continuous Eligibility

To promote stability and prevent gaps in coverage, the 2023 CAA not only made the 12-month postpartum Medicaid option permanent but also required all states to provide children under age 19 with 12 months of continuous Medicaid and CHIP eligibility beginning in January 2024. Several states went further by obtaining Section 1115 waiver approval to provide multi-year continuous eligibility, most commonly from birth through age 3 or age 6.

However, in July 2025, the Centers for Medicare and Medicaid Services (CMS) announced that it did not anticipate approving new multi-year continuous eligibility demonstrations or extending existing authorities beyond their expiration dates.51 CMS also directed states with expiring authorities to notify affected families, conduct eligibility redeterminations, and develop individualized plans for phasing out the policies.51

Nine states (Colorado, Hawaii, Minnesota, New Mexico, New York, North Carolina, Oregon, Pennsylvania, and Washington) had previously received approval to provide children with multi-year continuous eligibility. In December 2025, Colorado became the first state to have its authority expire without renewal. New York implemented continuous eligibility through age 6 in 2025 but enacted legislation in 2026 repealing the policy and returning children to 12-month eligibility periods beginning in July 2026. As of September 2026, the seven remaining states continued to operate active multi-year continuous eligibility policies, but their federal authorities are scheduled to phase out by 2029 unless federal policy changes.52

In 2025, at least eight states (Alaska, California, Illinois, Ohio, Maine, Montana, Rhode Island, and Texas) were considering steps toward multi-year continuous eligibility. So far this year, no state has taken significant action to establish or advance a new policy through this pathway.

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

The federal Medicaid changes enacted through OBBBA are already shaping state legislation, budgets, and administrative practices. In the year since enactment, states have begun implementing work requirements, preparing for 6-month redeterminations, modifying eligibility and immigration rules, upgrading eligibility systems, and deciding whether to adopt federal options that could reduce or increase the burden on applicants and enrollees. 

States have not responded uniformly to the new federal requirements. At least 13 states (Arkansas, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Montana, Nebraska, New Hampshire, North Carolina, Utah, and Wyoming) enacted legislation or took administrative action to impose requirements beyond OBBBA’s minimum rules or to begin implementation earlier than required. At least 11 additional states (Alabama, Arizona, Florida, Georgia, Idaho, Maryland, Minnesota, Mississippi, Missouri, Oklahoma, and West Virginia) considered, but did not enact, proposals that would have imposed requirements beyond federal minimums.

These state choices matter for families with young children even though children, pregnant people, postpartum people, and many parents of children under age 14 are excluded from OBBBA’s work requirement. States must still identify exemptions correctly, match information across multiple data systems, communicate new rules, and provide applicants and enrollees opportunities to correct missing or inaccurate information. Parents and other adults could still lose coverage when the state cannot verify an exemption automatically, even when they remain eligible.

OBBBA Replaced State-by-State Work Requirement Waivers, but State Implementation Varies

Before OBBBA, work requirements were largely pursued state by state through federal waivers. With the new federal requirement now mandatory for adults in the expansion population, states have instead focused on how quickly and how strictly to implement the new rules.53,54

In the last year, at least eight states (Colorado, Idaho, Indiana, Kentucky, Minnesota, New Hampshire, North Carolina, and Utah) enacted laws to begin implementing OBBBA’s work requirements. Though some states simply opted to put the federal rules into state law or established implementation and reporting processes, others adopted stricter rules that could require enrollees to prove compliance more often. Colorado, for example, enacted legislation to require the state to implement the work requirement and publicly report its effect on enrollment. Similarly, Minnesota directed the state Medicaid agency to specifically interpret eligibility “ambiguities” in ways that favor applicants and enrollees.

Five of the aforementioned states (Idaho, Indiana, Kentucky, New Hampshire, and North Carolina) took a different approach that could lead to additional administrative burden for households that are eligible for coverage. Idaho, Kentucky, and North Carolina enacted legislation requiring applicants to demonstrate compliance with work requirements for longer periods than required under OBBBA, and Kentucky and New Hampshire will require more frequent compliance checks. Indiana enacted legislation including both of these stricter provisions.

Finally, states have also taken varied approaches to their implementation timelines – OBBBA requires work requirements to be implemented by January 2027, but four states have elected to start sooner: Nebraska began enforcing work requirements in May 2026, and Arkansas and Montana began preliminary implementation in July 2026 by reviewing eligibility information to determine whether applicants and enrollees meet the work requirement or qualify for an exclusion. Though Arkansas will not terminate coverage for noncompliance until January 2027, Montana plans to begin doing so in October 2026. Iowa has indicated intentions to begin enforcement in December 2026.

The impact of these early implementation decisions on coverage is not yet known. However, there is broader evidence that the implementation timeline itself presents challenges for states. States have reported needing major eligibility system changes as well as new staffing, training, data-sharing, and outreach efforts to implement work requirements. More than half of states surveyed in early 2026 suggested they did not have enough time to add all of the new data sources they may need.55 The short federal timeline could increase the risk of errors or unnecessary coverage losses, and states starting earlier have had even less time to prepare.

Some States Added Administrative Rules Beyond OBBBA’s Minimum Eligibility Requirements

Beyond work requirements, several states enacted legislation that added eligibility and verification rules beyond OBBBA’s minimum requirements. These additional steps can increase administrative burden by requiring families to provide more information or respond to agency notices more often and can create more opportunities for eligible people to lose coverage for procedural reasons.

At least five states (Kansas, Kentucky, North Carolina, Utah, and Wyoming) enacted additional eligibility or verification requirements that could increase administrative burden for families by limiting the use of self-attested information or requiring more frequent reviews of eligibility records. Eight other states (Alabama, Arizona, Georgia, Maryland, Mississippi, Missouri, Oklahoma, and West Virginia) considered similar measures that did not pass.

At Least 4 States Enacted Stricter Enforcement of New Immigration Eligibility Rules

Beginning in October 2026, OBBBA will narrow federally funded Medicaid eligibility for many lawfully present immigrants. Four states (Iowa, Louisiana, Utah, and Wyoming) went further than what OBBBA requires by enacting legislation that adds more extensive citizenship or immigration verification to their Medicaid eligibility processes. Iowa required the state to verify citizenship and immigration information through a federal database, whereas Utah and Wyoming limited the ability of applicants to self-attest to their legal status without additional verification. The bills in Louisiana and Wyoming also require the state to notify federal immigration authorities when an applicant’s legal status cannot be confirmed.

Other states, including Maryland, Mississippi, Missouri, and West Virginia all introduced similar bills that would have imposed stricter immigration eligibility or verification requirements, but those proposals did not pass this session.

States Invested in Eligibility Systems and Strategies That Could Reduce Administrative Burden

At least 10 states considered legislation to modernize eligibility systems, automate data-matching, coordinate benefit administration, or other system changes related to OBBBA’s implementation. Seven states (California, Colorado, Iowa, Minnesota, Missouri, New Jersey, and Vermont) enacted legislation, and three states (Connecticut, New York, and Virginia) introduced proposals that did not pass. Some of these investments are primarily intended to give states the capacity to carry out OBBBA’s new requirements, and others more directly aim to make enrollment and renewal easier for families.

Among the states that enacted changes, Iowa, Minnesota, and Missouri made substantial investments in the systems used to determine eligibility and manage benefits. New Jersey invested in web-based tools designed to connect residents with volunteer opportunities that satisfy the OBBBA’s work requirements for Medicaid. Other states proposed changes more directly aimed at making enrollment easier. Connecticut proposed greater use of automatic renewals, data matching, and self-attestation; New Jersey considered a common application for public benefits and use of tax data to streamline enrollment; and New York considered obtaining income and employment information directly from existing databases rather than requiring applicants to provide it themselves. These bills did not pass this session.

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 ($15,960 annually for an individual). 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 ($22,025 annually for an individual) are eligible for Medicaid in expansion states.

For parents with low incomes in nonexpansion states, income eligibility varies from as low as 15% of the FPL in Texas ($4,098 annually for a family of three) to up to 105% of the FPL in Tennessee ($28,686 annually for a family of three). In expansion states, parents with incomes at or below 138% of the FPL are eligible ($37,702 annually for a family of three).

Notably, in the last year, the District of Columbia reduced its parent Medicaid eligibility threshold from 215% to 138% for childless adults and from 221% to 138% of the FPL for parents. However, the District concurrently established the Healthy DC Plan – a separate, no-cost health coverage program designed to provide coverage to many of those losing Medicaid who have incomes between 138% and 200% of the FPL. According to District officials, more than 14,700 former Medicaid enrollees had moved to the Healthy DC Plan within a week of its launch in January 2026.56

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 28 states, the income eligibility threshold for pregnant individuals is at least 200% of the FPL ($54,640 annually for a family of three). In two of these states (the District of Columbia and Wisconsin), the threshold is greater than 300% of the FPL ($81,960 annually for a family of three). Until 2025, Iowa had the most generous Medicaid eligibility threshold for pregnant individuals, at 380% of the FPL. When the state implemented its 12-month postpartum extension in April 2025, it also reduced the pregnancy eligibility threshold to 220% of the FPL. The District of Columbia now has the most generous threshold for pregnant individuals, at 324% of the FPL.

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 ($37,702 for a family of three), which is also the standard for parents in those states.

Women of Childbearing Age Lack Access to Health Care That Could Support Healthier Perinatal Outcomes and Strong 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, Maine, Massachusetts, 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 41.8% of income-eligible women in the state lacking health insurance. Nationally, approximately one in five (20.1%) income-eligible women is uninsured.

Click here to view the compiled 2026 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. Osterman, M.J.K., Hamilton, B.E., Martin, J.A., Driscoll, A.K. & Valenzuela, C.P. (2026). Births: Final Data for 2024. National Vital Statistics Reports. 75(2):1-47. https://stacks.cdc.gov/view/cdc/252440
  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. (2026, July 15). Medicaid postpartum coverage extension tracker. KFF. https://www.kff.org/medicaid/issue-brief/medicaid-postpartum-coverage-extension-tracker/
  14. Cervantes, S., Bell, C., Tolbert, J., & Damico, A. (2026, July 27). How Many Uninsured Are in the Coverage Gap and How Many Could be Eligible if All States Adopted the Medicaid Expansion? KFF. 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. Buettgens, M., Carter, J., Karpman, M., Kenney, G. M., & Haley, J.M. (2026, March) Projected reductions in Medicaid expansion enrollment under OBBBA’s work requirements and six-month redeterminations: National and state estimates for 2028. Urban Institute. https://www.urban.org/research/publication/projected-reductions-medicaid-expansion-enrollment-under-obbbas-work 
  23. 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/
  24. 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]
  25. 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]
  26. 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]
  27. 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. https://doi.org/10.1111/1475-6773.13286 [Expanded Income Eligibility for Health Insurance Evidence Review Study V] 
  28. 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] 
  29. 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
  30. 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]
  31. 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]
  32. 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]
  33. 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]
  34. 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]
  35. 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]
  36. 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]
  37. 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]
  38. Congressional Budget Office. (2025, October). Supplemental Cost Estimate, Public Law 119-21. https://www.cbo.gov/system/files/2025-10/PL-119-21-Medicaid%20_0.pdf
  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 Budget Office. (2025, October). Supplemental Cost Estimate, Public Law 119-21. https://www.cbo.gov/system/files/2025-10/PL-119-21-Medicaid%20_0.pdf
  41. Congressional Budget Office. (2025, October). Supplemental Cost Estimate, Public Law 119-21. https://www.cbo.gov/system/files/2025-10/PL-119-21-Medicaid%20_0.pdf
  42. Burak, E. W., & Johnson, K. (2026, June). Medicaid Work Reporting Requirements: How Can States Protect Pregnant and Postpartum Women from Losing Health Coverage? Georgetown University Health Policy Institute: CCF. https://ccf.georgetown.edu/2026/07/17/medicaid-work-reporting-requirements-how-will-states-protect-coverage-for-pregnant-and-postpartum-women/
  43. Congressional Budget Office. (2025, October). Supplemental Cost Estimate, Public Law 119-21. https://www.cbo.gov/system/files/2025-10/PL-119-21-Medicaid%20_0.pdf
  44. Broder, T. (2026, March) Medical Assistance Programs for Immigrants in Various States. National Immigration Law Center. https://www.nilc.org/resources/medical-assistance-various-states/
  45. Congressional Research Service. (2025, April). Medicaid’s Federal Medical Assistance Percentage (FMAP). U.S. Congress. https://www.congress.gov/crs_external_products/R/PDF/R43847/R43847.13.pdf
  46. 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/
  47. Park, E. (2026, July). CMS Issues New Rule Again Going Beyond H.R. 1 Requirements to Further Restrict State Use of Medicaid Provider Taxes. Georgetown University Health Policy Institute: CCF. https://ccf.georgetown.edu/2026/07/27/cms-issues-new-rule-again-going-beyond-h-r-1-requirements-to-further-restrict-state-use-of-medicaid-provider-taxes/
  48. 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/
  49. Mudumala, A., & Tolbert, J. (2026, May) Understanding Medicaid Cost Sharing and Policy Changes from the 2025 Reconciliation Law. KFF. https://www.kff.org/medicaid/understanding-medicaid-cost-sharing-and-policy-changes-from-the-2025-reconciliation-law/
  50. 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
  51. 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
  52. 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/
  53. Georgetown University Health Policy Institute: CCF. (2026). Tracking Implementation of H.R. 1 Medicaid Work Reporting Requirements. https://ccf.georgetown.edu/feature/tracking-implementation-of-h-r-1-medicaid-work-reporting-requirements/
  54. KFF (2026). Tracking Implementation of the 2025 Reconciliation Law: Medicaid Work Requirements. https://www.kff.org/medicaid/medicaid-work-requirements-tracker-overview/
  55. Tolbert, J., Diana, A., Mudumala, A., Brooks, T., Yafimenka, Y., & Lin, A. (2026, April). An Early Look at Policy Decisions as States Get Ready to Implement Work Requirements: Results from the 2026 Medicaid Eligibility, Enrollment, and Renewal Policies Annual Survey. https://www.kff.org/medicaid/an-early-look-at-policy-decisions-as-states-get-ready-to-implement-work-requirements/
  56. Henderson, C. (2026, February). Fiscal Year 2025 Performance Oversight Pre-Hearing Questions. DC Council Committee on Health, Department of Health Care Finance. https://dccouncil.gov/wp-content/uploads/2026/02/DHCF-FY25-26-Performance-Oversight-Responses.pdf
  57.  

Follow us:

Twitter Facebook Linkedin Youtube
Newsletter Sign-up