In 2010, Congress passed the Affordable Care Act (aka, “Obamacare”) and President Obama signed it into law.  One of the main provisions related to Medicaid.  This is a program that provides medical insurance for people with incomes at or below 138% of the poverty line.  It is a joint program between the federal government and each state, with the feds matching state expenditures dollar for dollar.

However, in 2014, the year that Obamacare was implemented, the federal government began to pay 100% of the cost of new Medicaid enrollees in states that accepted the new benefit.  States that embraced the program are “expansion states” and those that did not accept the expanded Medicaid benefit are “nonexpansion states.”


Expansion states that engaged the new Medicaid benefit in 2014 have experienced a 44% reduction in average per capita medical indebtedness compared to nonexpansion states. The regional breakdown was stark: in the Northeast, mean medical debt is now $167, whereas in the South, it is $616. In 2015, across the entire country, 23.8% of the population reported past due medical debts. The figure in 2020 was 17.8%.

Nor are the benefits limited to a reduction in medical debt. In expansion states, access and use of medical care increased.. Food and housing insecurity decreased. Medical outcomes, especially in maternal and fetal health, improved. Racial disparities in medical insurance diminished. And aggravated assaults went down.

A Ways to Go

At the time of implementation of Obamacare, 24 states opted out of the new benefit. To date, 11 states remain nonexpansion states, nine of which are in the South along with Wyoming and Wisconsin. Six states (Maine, Utah, Idaho, Nebraska, Oklahoma, and Missouri) have skirted their recalcitrant state governments and obtained the expansion benefit by means of state referenda.

There is much to be done. In 2020, 66.5% of bankruptcies were directly caused by medical expenses. Although the 8.6 % of medically uninsured Americans is at an all time low, this statistic could be easily reduced. If all of the states that have opted out of Obamacare’s Medicaid expansion were to join in, an additional 3.7 million Americans would gain medical coverage.



  1. Peter Beatty says:

    In light of such an obviously beneficial program in terns of real health benefits as well as economic outcomes, how do the opponents in Wyoming,Wisconsin, and the South defend their decision to not participate in the expansion program now that the outcome data are available? What is their excuse?

  2. Thanks, Jim, for presenting in detail the results of political stands that hurt the less fortunate supported by the voting choices of the fortunate.

  3. Pam Brindley says:

    Jim may I share with my associates in the Minnesota AAHAM group? These patient account managers, billers and collectors deal with medical debt daily.

Leave a Reply