Just 10 states have refused to expand Medicaid under the Affordable Care Act—and that trend is likely to continue—though a second Trump term could change a few states’ hearts, analysts with strategy firm Capstone said in a new report.
That’s because several states are willing to expand Medicaid if there are work requirements tied to the policy, provisions that are opposed by the Biden administration but championed by Republicans.
Work requirement proposals usually require Medicaid beneficiaries to prove they are working to obtain coverage. The remaining 10 states are overwhelmingly run by Republican governors and state legislatures.
By 2027, Capstone puts Kansas and Mississippi at a 50% likelihood of expanding Medicaid. Both states seem willing to compromise on work requirements. Were they to go ahead with expansion, an estimated 352,000 people would be covered.
“States expanding Medicaid with work requirements will limit expansion enrollment, restricting the upside of expansion, even as it increases the likelihood of expansion,” the analysts wrote.
The other eight states are given a 25% chance or less of expanding Medicaid, led by Georgia, Wisconsin, Alabama and Florida, analysts wrote. These states are highly skeptical of the proposal and would require provisions unpopular with Democrats. In the case of Georgia, the state has already adopted partial expansion with work requirements but no matching federal funds.
Under the American Rescue Plan Act (ARPA), states can receive a 5% increase to the Federal Medical Assistance Percentage for two years.
Studies have consistently found that work requirements adversely impact the number of individuals able to enroll in Medicaid,” the report said. “Further, disenrollments due to work requirements include noncompliant and compliant individuals, largely because of administrative complexity”
It’s possible a President Trump-run Department of Health and Human Services would push for work requirements again, reported Politico. During Trump’s first term, 13 states had work requirements approved, but President Biden revoked work requirement waivers. The Heritage Foundation’s Project 2025, supported by officials close to President Trump, also calls for “drastic” cuts to Medicaid, says the Georgetown Center for Children and Families.
Large health systems and insurers could benefit from Medicaid expansion in these states, though the benefit is less pronounced if states require work requirements. Hospitals see a significant part of their operating income from Medicaid beneficiary spending.
One of the country's largest for-profit health systems, Community Health Systems (CHS) would see $240 million more annual revenue, which is 28% of their operating income.
“HCA Healthcare is best poised to capture expansion revenue lift under full expansion,” the report explained. “However, given the probability of expansion, [CHS] is likely to see the most significant lift.”
Managed care organizations like Centene and Molina Healthcare would also see revenue tailwinds if holdout states expanded Medicaid.
“Centene is better positioned to capture expansion revenue than Molina is, which is driven by larger market share in holdout states,” analysts said. “Molina benefits from having a greater share of its lives in positive outlook states, despite smaller overall tailwinds. Mississippi, given its more positive outlook, is the best opportunity for both Molina and Centene.”
Under full expansion, Centene would receive more than $5 billion in annual revenue, driven primarily by Florida. Molina would see $600 million more revenue, largely due to Florida and Texas.