12 states still refuse to expand Medicaid. Why that’s a problem for all of us

In 2020, Missouri residents voted to expand Medicaid, the federal health insurance program for the poor. Under the terms of the 2010 Affordable Care Act, the federal government contributes more generous funding to states that offer expanded access to the program to their residents. In Missouri, expansion would have meant an estimated 275,000 more people would have become eligible.

But in the spring, Missouri’s legislature refused to include funds for the expansion in the state budget, and in May, Gov. Mike Parsons declined to implement the unfunded program.

Finally, in August, a year after the referendum passed, Missouri’s state supreme court ruled that lawmakers had to proceed with the expansion. 

Expansion isn’t costless: the Missouri legislature estimated it would have cost $156 million in the current fiscal year. But those expenses are “dwarfed,” in the words of Tax Policy Center senior policy associate Richard Auxier, by the amount of federal funds that flow to the state once expansion is under way, not to mention the broader benefits of increased health insurance. 

With Missouri now legally decided, 12 other states, mostly Republican-led, are still expansion holdouts — and seem unlikely to budge, despite the roughly 11 years that have passed since the ACA was passed and 18 months into a global health pandemic. That’s a problem, not just for their residents but for the country as a whole, say professionals in public health and public finance.