The Supreme Court's 2012 ruling on the Affordable Care Act (ACA) allowed states to opt out of the law's Medicaid expansion, leaving each state's decision to participate in the hands of the nation's governors and state leaders.

Now, amid perennial debate over whether to repeal and replace the Affordable Care Act, the fate of Medicaid expansion remains uncertain. However, the Nov. 6 midterm elections proved significant as voters in three conservative states decided to expand coverage to hundreds of thousands of people, while voters in Montana chose to allow their state's Medicaid expansion to expire in 2019.

The Daily Briefing editorial team has been tracking where each state stands on Medicaid expansion, combing through lawmakers' statements, press releases, and media coverage. In this latest iteration of our Medicaid map, we've determined each state's position and outlined any possible expansion efforts.

We will continue to update this map as more information becomes available. Send us news, tips, and feedback by commenting below or emailing dailybriefing@advisory.com.

A state-by-state look at expansion

Expanding coverage (36 States and Washington, D.C.)

• Alaska: Then-Gov. Bill Walker (I) on July 16, 2015, announced he would use his executive power to expand Medicaid to about 40,000 additional residents. The state's Medicaid expansion went into effect on Sept. 1, 2015.
• Arizona: On June 17, 2013, then-Gov. Jan Brewer (R) signed into law legislation that expanded Medicaid to an additional 350,000 people in the state. The signing came after Brewer called a surprise special session on the 2014 budget and Medicaid to try to resolve a deadlock among lawmakers on the two issues. The state implemented Medicaid expansion on Jan. 1, 2014. In September, 2016, CMS approved a state waiver proposal to require certain cost-sharing methods.
• Arkansas: Then-Gov. Mike Beebe (D) on April 23, 2013, signed the state's expansion plan into law. Under the plan, Arkansas accepts federal money for Medicaid expansion provided through the ACA but uses it to buy private insurance for about 250,000 eligible low-income residents. The state implemented Medicaid expansion on Jan. 1, 2014. Current Gov. Asa Hutchinson (R) in June 2017 submitted a Medicaid waiver request seeking to scale back its alternative Medicaid expansion in part by capping eligibility for the program at 100 percent of FPL, down from 138 percent of FPL. CMS rejected that request but approved other changes such as eliminating retroactive eligibility.
• California: Then-Gov. Jerry Brown (D) on June 27, 2013, signed legislation that expanded the state's Medicaid program, Medi-Cal, to more than 1.4 million additional residents under the ACA. The state implemented Medicaid expansion on Jan. 1, 2014.
• Colorado: Then-Gov. John Hickenlooper (D) signed the expansion into law on May 13, 2013. He said that the expansion will save the state $280 million over 10 years and help cover an additional 160,000 adults. The state implemented Medicaid expansion on Jan. 1, 2014.
• Connecticut: Gov. Dannel Malloy (D) was among the first governors to sign up for the Medicaid expansion after the ACA was enacted. The state was one of five states that opted to expand eligibility early. The state implemented Medicaid expansion on Jan. 1, 2014.
• Delaware: Then-Gov. Jack Markell (D) on July 1, 2013, signed a FY 2014 budget plan that includes $29.8 million to "fund the State's Medicaid commitment." The state implemented Medicaid expansion on Jan. 1, 2014. More than 10,000 state residents have enrolled in the expanded coverage.
• District of Columbia: District officials sought permission from the federal government to expand its Medicaid program on May 13, 2010. The state implemented Medicaid expansion on Jan. 1, 2014. The move expanded Medicaid to an additional 35,000 residents.
• Hawaii: Then-Gov. Neil Abercrombie (D) in a statement on June 28, 2012, said, "The Affordable Care Act is our ally in this effort" to "to support a healthcare system that ensures high quality, safety and sustainable costs." The state implemented Medicaid expansion on Jan. 1, 2014.
• Idaho: In the November 2018 elections, 62% of voters approved an expansion measure, which directs the state to expand Medicaid to individuals with annual incomes up to 138% of the federal poverty line. Medicaid expansion took effect January 2020. State officials in June said about 80,000 people had signed up for the expanded Medicaid program as of early June
• Illinois: Then-Gov. Pat Quinn (D) signed Medicaid expansion into law on July 22, 2013. Approximately 342,000 low-income Illinois residents will be newly insured under the expansion. The state implemented Medicaid expansion on Jan. 1, 2014.
• Indiana: The federal government on Jan. 27, 2015, approved Indiana's alternate Medicaid expansion plan, known as Healthy Indiana Plan 2.0. In a major concession, federal authorities allowed Indiana to lock residents out of the program for six months if they fail to pay premiums. The state implemented Medicaid expansion on Feb. 1, 2015.
• Iowa: On Dec. 12, 2013, then-Gov. Terry Branstad (R) announced that his administration and the White House had agreed on the final details of his plan to expand Medicaid. The state implemented Medicaid expansion on Jan. 1, 2014. Under the agreement, Iowa since 2015 has levied an additional premium on individuals with incomes exceeding 50% of the federal poverty level. The state promised that it will not drop individuals' coverage if they fail to make payments. The agreement also allows the state to use federal funding under the ACA to help more than 100,000 low-income residents purchase private health coverage through the new Iowa Health and Wellness Plan.
• Kentucky: Then-Gov. Steve Beshear (D) in 2014 expanded Medicaid in Kentucky via executive order. Under Gov. Matt Bevin (R), elected in November 2015, Kentucky in 2018 received CMS approval to alter the state's Medicaid expansion, including by implementing new cost-sharing requirements and eliminating coverage for dental and vision services. Kentucky in 2018 also became the first state to win federal approval to test work requirements for Medicaid beneficiaries, a decision that was blocked by a federal judge in June 2018 and again in March 2019. On November 5, 2019, state voters elected Attorney General Andy Beshear (D) to be Kentucky's next governor, and Beshear has taken steps to walk back the state's Medicaid work requirements.
• Louisiana: On Feb. 6, 2013, then-Gov. Bobby Jindal (R) reiterated his opposition to expanding Medicaid in Louisiana. But in June 2015, the Louisiana state Legislature passed a veto-proof bill to create a funding plan for Medicaid expansion, in part by allowing the Louisiana Hospital Association's members to pay for a portion of the state's costs. In November 2015, Louisiana voters elected state Rep. John Bel Edwards (D) to be the state's next governor. On his second day in office—Jan. 12, 2016—Edwards signed an executive order to expand Medicaid in the state. The state implemented Medicaid expansion on July 1, 2016. In February 2017, the Louisiana Department of Health announced that more than 400,000 individuals had enrolled in coverage under the state's Medicaid expansion.
• Maine: Former Maine Gov. Paul LePage (R) was a stark opponent to Medicaid expansion and vetoed several Medicaid expansion bills passed by the state Legislature. In November 2017, Maine voters approved a referendum to expand Medicaid under the ACA to an estimated 80,000 state residents. On January 10, 2019, Maine implemented Medicaid expansion, after newly elected Gov. Janet Mills (D) signed an executive order directing the Maine Department of Health and Human Services to begin expansion implementation and provide coverage to those eligible retroactive to July 2018.
• Maryland: On May 5, 2013, then-Gov. Martin O'Malley (D) signed into law HB 228 to expand Medicaid. The state implemented Medicaid expansion on Jan. 1, 2014. Officials projected about 165,000 state residents would enroll in the expanded Medicaid program in fiscal year 2015.
• Massachusetts: On July 5, 2013, then-Gov. Deval Patrick (D) signed into law HB 3452, requiring Massachusetts to expand Medicaid under the ACA. The state implemented Medicaid expansion on Jan. 1, 2014. Under current Gov. Charlie Baker (R), the state in September 2017 submitted a waiver request seeking to move certain enrollees into subsidized exchange plans to curtail state Medicaid spending. The request was still pending as of Oct. 2.
• Michigan: Gov. Rick Snyder (R) on Sept. 16, 2013 signed into law a bill to expand the state's Medicaid program beginning in April 2014. The law contains cost-sharing provisions for Medicaid beneficiaries; it received federal approval in December 2013. The state implemented Medicaid expansion on April 1, 2014.
• Minnesota: Gov. Mark Dayton (D) in February 2013 signed legislation that expanded Medicaid to an additional 35,000 childless, low-income adults in the state. The state implemented Medicaid expansion on Jan. 1, 2014.
• Montana: Then-Gov. Steve Bullock (D) on April 29, 2015, signed legislation that expanded eligibility for Medicaid to about 70,000 state residents. On November 2, 2015, CMS approved Montana's alternative Medicaid expansion plan, which requires some beneficiaries in the expansion population to pay premiums equivalent to 2% of their income, as well as pay copayments. Coverage began on Jan. 1, 2016. Montana Gov. Steve Bullock (D) in 2019 signed into law a bill extending the state's Medicaid expansion for an additional six years on the condition that state officials to seek federal approval for Medicaid work requirements.
• Nebraska: In May 2013, Republicans in the Legislature filibustered a proposal to expand Medicaid, which was also opposed by then-Gov. Dave Heineman (R). On Nov. 6, 53% of voters approved a measure, which directs the state to expand Medicaid to individuals with annual incomes up to 138% of FPL. Under the measure, the state will expand Medicaid coverage to an estimated 90,000 Nebraska residents. The state's Medicaid expansion took effect on Oct. 1. CMS on Tuesday approved Nebraska's plan to expand its Medicaid program with a two-tiered approach that will require certain beneficiaries to work, volunteer, attend school, or receive job training in order for coverage of extra health care services.
• Nevada: Gov. Brian Sandoval (R) in December 2012 became the first GOP governor to commit his state to expanding Medicaid under the ACA. According to Sandoval's announcement, nearly 78,000 Nevadans would be covered by the expansion. The state implemented Medicaid expansion on Jan. 1, 2014.
• New Hampshire: On March 27, 2014, then-Gov. Maggie Hassan (D) signed bipartisan legislation (SB 413) to expand Medicaid coverage to an estimated 50,000 low-income state residents. The state implemented Medicaid expansion on Aug. 15, 2014. Under a waiver approved by CMS on March 4, 2015, New Hampshire began enrolling certain Medicaid beneficiaries in private coverage through the ACA insurance exchange in 2016.
• New Jersey: Gov. Chris Christie (R) on June 28, 2013, signed a state budget that includes $227 million for Medicaid expansion in the state. The state implemented Medicaid expansion on Jan. 1, 2014. Officials estimated that in 2014 about 300,000 uninsured state residents would be insured under the expansion.
• New Mexico: Gov. Susana Martinez (R) on Jan. 9, 2013, announced that the state would participate in the Medicaid expansion. The state implemented Medicaid expansion on Jan. 1, 2014.
• New York: On June 28, 2012, in an announcement immediately following the Supreme Court's ruling on the ACA, Gov. Andrew Cuomo (D) said the state would participate in the expansion. The state implemented Medicaid expansion on Jan. 1, 2014.
• North Dakota: Then-Gov. Jack Dalrymple (R) in April 2013 signed legislation expanding Medicaid in the state. The state implemented Medicaid expansion on Jan. 1, 2014.
• Ohio: The state's Controlling Board—a special bipartisan legislative panel—approved Medicaid expansion in 5-2 vote on Oct. 21, 2013, allowing Gov. John Kasich (R) to expand the program on Jan. 1, 2014, without approval from Ohio's Republican-controlled Legislature. In 2019, CMS approved a waiver request to add work requirements for some of the state's Medicaid expansion population.
• Oregon: The state in 2013 moved forward with Medicaid expansion with the support of then-Gov. John Kitzhaber (D). State residents with incomes of up to 138% poverty level began to qualify for Medicaid starting on Jan. 1, 2014. On Nov. 6, 2018, 61% of voters approved Measure 101, which directs the state to continue implementing taxes on health insurance and hospital revenue to fund its Medicaid expansion.
• Pennsylvania: HHS on Aug. 28, 2014, reached a deal with then-Gov. Tom Corbett (R) to expand  Medicaid coverage to as many as 600,000 Pennsylvania residents. The state obtained a waiver for an alternate expansion model, which included premiums for certain beneficiaries. The expansion began on Jan. 1, 2015. However, Corbett was defeated by current Gov. Tom Wolf (D) in the 2014 elections. Wolf in February 2015 announced plans to replace the alternate expansion plan with a traditional Medicaid expansion. The state completed the transition to traditional Medicaid expansion in September 2015.
• Rhode Island: On July 3, 2013, about one week before the state General Assembly adjourned for the year, then-Gov. Lincoln Chafee (I) signed a fiscal year 2014 budget measure that included a plan to expand Medicaid in 2014. The state implemented Medicaid expansion on Jan. 1, 2014.
• Utah: In the November 2018 elections, 53% of voters approved a ballot proposal that would expand Medicaid under the ACA to individuals with annual incomes up to 138% of FPL, which the state estimated would expand the program to about 150,000 Utah residents. However, the state's Legislature this year passed a measure, which Utah Gov. Gary Herbert (R) signed it into law, that would limit the expansion to residents with incomes less than or equal to 100% FPL and impose work requirements on those individuals. CMS in March approved Utah's partial Medicaid expansion, and the state began implementing the expansion on April 1, 2019. Utah is now seeking another waiver to fully expand Medicaid under the ACA beginning Jan. 1, 2020.
• Virginia: Gov. Ralph Northam on June 7 signed into law a bill that expands Medicaid coverage to up to 400,000 low-income residents and instructs state officials to apply for a federal waiver to impose work or volunteer requirements and premiums on certain beneficiaries. The state's Medicaid expansion took effect Jan. 1, 2019.
• Vermont: Then-Health Care Access Commissioner Mark Larson in July 2012 said that Vermont would receive federal funds to expand its Medicaid program to a projected 47,000 additional state residents through the ACA. The state implemented Medicaid expansion on Jan. 1, 2014.
• Washington: Gov. Jay Inslee (D) on June 30, 2013, signed a state budget that expanded Medicaid in the state. The state implemented Medicaid expansion on Jan. 1, 2014.
• West Virginia: Then-Gov. Earl Ray Tomblin (D) in May 2013 announced that the state would expand Medicaid, extending coverage to an additional 91,500 state residents. The state implemented Medicaid expansion on Jan. 1, 2014.