State-by-State Medicaid Coverage Changes 2024–2026: Who Gained, Who Lost, Why
Medicaid enrollment peaked at 94 million in January 2023 and has since dropped to 74.3 million — a 21% decline that played out very differently across the 50 states. Expansion vs. non-expansion, red vs. blue, aggressive vs. cautious — here's the comprehensive state-by-state picture.
The National Picture
The trajectory from peak to present tells a clear story: COVID inflated Medicaid rolls by 32%, and the unwinding brought them back down — but not evenly. Every state experienced enrollment declines, but the magnitude ranged from 11% (Connecticut) to31% (Indiana).
Peak enrollment: 94 million. Three years of continuous enrollment created the highest rolls in Medicaid history.
Down to 85 million. First wave of unwinding disenrollments hit, mostly procedural.
Down to 78 million. Most states completed initial redeterminations. Pace of decline slowing.
Current: 74.3 million. Enrollment stabilizing, but work requirements loom.
Expansion vs. Non-Expansion: The Divide
As of mid-2026, 40 states plus DC have expanded Medicaid under the ACA, covering adults up to 138% of the federal poverty level. The remaining 10 states have not expanded (though Georgia has a partial expansion waiver). This divide fundamentally shaped how the unwinding played out:
Expansion States (40 + DC)
- Average enrollment decline: 16%
- Higher FMAP (90%) incentivized retention efforts
- More ex parte renewal capacity
- Broader eligible population = larger base
- More experience with eligibility systems
Non-Expansion States (10)
- Average enrollment decline: 22%
- Standard FMAP (50-77%) = less federal support
- Narrower eligibility = fewer people qualify
- Less investment in renewal infrastructure
- Higher procedural disenrollment rates
States With the Biggest Drops
Six states stand out for particularly steep enrollment declines:
Aggressive redeterminations, minimal outreach, no expansion buffer
Fastest unwinding timeline, non-expansion, high procedural rate
Limited expansion via waiver, narrow eligibility
Block grant waiver, strictest redetermination standards
Recent expansion state, still building infrastructure
Gateway to Work waiver, highest % decline nationally
States Holding Steady
In contrast, several states managed to limit enrollment losses through aggressive outreach, automatic renewals, and investment in eligibility infrastructure:
Strong outreach, automatic renewals, $150M renewal investment
Largest program, invested $200M+ in renewal infrastructure
Best ex parte renewal rate nationally (82%), robust navigator program
MinnesotaCare bridge coverage, strong community health worker network
Smallest decline among large states, aggressive re-enrollment campaigns
🤔 Is "Holding Steady" Always Good?
Lower enrollment declines aren't automatically a sign of success. States that spent heavily to retain enrollees may have kept people on the rolls who no longer qualified — essentially using taxpayer money to delay inevitable disenrollments. Massachusetts's 82% ex parte renewal rate is impressive, but it also means 82% of renewals were approved without the enrollee lifting a finger. Whether that reflects efficient government or insufficient verification is a matter of perspective.
Work Requirements: The Next Wave
The reconciliation law signed in early 2026 requires work reporting for non-disabled, non-pregnant expansion adults ages 19-64 starting January 2027. 44 states are expected to implement these requirements, with CBO projecting 8-10 million expansion adults subject to work reporting.
The precedent from Arkansas's 2018-2019 work requirements is instructive — and concerning. In just 10 months, 18,000 people (about 25% of the affected population) lost coverage, primarily for reporting failures rather than not meeting work requirements. If national implementation follows a similar pattern, millions could lose coverage.
Work Requirements Implementation Status
States Preparing Early
- Indiana — Existing Gateway to Work infrastructure
- Arkansas — Rebuilt system from 2018 experience
- Ohio — Integrating with workforce development
- Montana — HELP Act framework already in place
States Facing Challenges
- California — 12.1M enrollees, massive scale
- New York — Political resistance, complex system
- Illinois — Legacy IT systems need overhaul
- Michigan — Rural areas lack reporting access
FMAP Changes and Fiscal Cliffs
The federal share of Medicaid expansion costs is scheduled to decline from 90% to 80% by 2028 under the reconciliation law. This 10-percentage-point shift means states will pay double their current share of expansion costs — from 10% to 20%. For large expansion states, this translates to billions in additional state spending.
States most at risk from the FMAP reduction are those with large expansion populations and tight budgets. Ohio (1.8M expansion enrollees), Michigan (1.1M), and Pennsylvania (1.0M) face the biggest fiscal exposure. Some analysts predict 3-5 states could roll back expansion entirely if the math doesn't work.
Per-Capita Spending: A 3.5x Gap
Medicaid spending per enrollee varies enormously — from about $4,000 in Mississippi to $14,000 in New York. This 3.5x gap reflects fundamentally different programs operating under the same federal framework.
Highest per-capita, driven by long-term care costs
High managed care rates, generous benefits
Comprehensive benefits, high provider rates
Largest total spend, moderate per-capita
Low per-capita, non-expansion
Low per-capita, non-expansion, heavy managed care
Lowest per-capita nationally, non-expansion
Section 1115 Waiver Innovations
Several states are using Section 1115 waivers to reshape their Medicaid programs in ways that go well beyond traditional coverage. These experimental models are worth watching as the program evolves:
Premium assistance model using marketplace plans for expansion adults. Work requirements approved.
Partial expansion to 100% FPL with work/community engagement requirements.
Health savings account model with work requirements. Lockout provisions for non-compliance.
Expansion with community engagement, premium requirements above 50% FPL.
Specialized managed care for children with complex behavioral health needs.
Housing supports, nutrition services as covered Medicaid benefits. Continuous eligibility for children 0-6.
Political Dynamics: Red vs. Blue
The Medicaid landscape increasingly mirrors the partisan divide:
Red State Trends
- 10 states still haven't expanded Medicaid
- Embracing work requirements enthusiastically
- Pursuing Section 1115 waivers with conservative features (premiums, lockouts, HSAs)
- Lower per-capita spending, narrower benefits
- Faster unwinding timelines, higher disenrollment rates
Blue State Trends
- All expanded Medicaid, some covering above 138% FPL
- Resisting work requirements (legal challenges expected)
- Using waivers for social determinants (housing, nutrition)
- Higher per-capita spending, broader benefits
- Investing in retention infrastructure, slower unwinding
The irony: red states with the narrowest Medicaid programs often have the highest rates of uninsured residents. Texas (17.3% uninsured), Georgia (13.4%), and Florida (12.8%) lead the nation. Whether this reflects principled limited government or a coverage gap that harms working families depends on your political prism.
What to Watch: 2026-2027
- Work requirements launch (Jan 2027) — The biggest enrollment disruptor since the unwinding. Implementation quality will vary wildly.
- FMAP reduction to 85% (2027) — First step down. Watch for states signaling expansion rollback.
- Immigrant eligibility changes (Oct 2026) — Certain immigrant populations lose Medicaid access. Could affect 1-2 million enrollees.
- Six-month redeterminations — States must verify eligibility twice yearly. Will catch changes faster but increase administrative burden.
- Legal challenges — Multiple states expected to challenge work requirements. Courts could block or delay implementation.
Bottom Line
Medicaid is increasingly 50 different programs rather than one national safety net. The gap between a New York enrollee receiving $14,000 in annual per-capita benefits with comprehensive coverage and a Mississippi enrollee receiving $4,000 with bare-bones benefits grows wider each year.
The post-unwinding stabilization at 74.3 million is temporary. Work requirements, FMAP reductions, and six-month redeterminations will push enrollment lower — potentially below the pre-pandemic 71 million baseline by late 2027. Whether that represents appropriate program right-sizing or a coverage crisis depends on how well states implement the new rules and whether the people leaving Medicaid are landing in other coverage or joining the uninsured.
The data suggests it will be both — some states will manage the transition well, others won't. The 50-state experiment continues.
Frequently Asked Questions
How many people are currently enrolled in Medicaid?
As of mid-2026, approximately 74.3 million people are enrolled in Medicaid and CHIP combined. This is down from the all-time peak of 94 million in March 2023 when COVID-era continuous enrollment ended, but still about 4% above the pre-pandemic baseline of 71 million in February 2020.
Which states lost the most Medicaid enrollment?
Indiana had the largest percentage decline at 31%, followed by Florida and Georgia (both around 25%), Tennessee (25%), Missouri (23%), and Texas (17%). Non-expansion states and states with aggressive redetermination timelines generally saw the steepest drops. Florida's 24% decline was notable given its large population — representing about 1.2 million people.
How do expansion states compare to non-expansion states?
Expansion states generally had smaller enrollment declines (13-17%) compared to non-expansion states (17-25%). Expansion states benefited from higher FMAP rates that incentivized retention efforts, more experience with eligibility systems, and broader eligible populations that provided a larger base. However, some expansion states like Indiana (31%) and Missouri (23%) saw large declines due to waiver complications or recent expansion with immature systems.
How will work requirements affect state enrollment?
Work requirements take effect January 2027 under the reconciliation law, with 44 states expected to implement them. CBO estimates 8-10 million expansion adults could face work reporting requirements. Based on Arkansas's 2018-2019 experience, where 18,000 lost coverage in 10 months (about 25% of the affected population), national implementation could result in millions of additional disenrollments. States with strong existing workforce programs and reporting infrastructure will likely see less disruption.
What is FMAP and why does it matter for state coverage?
FMAP (Federal Medical Assistance Percentage) is the share of Medicaid costs the federal government pays. It ranges from 50% (wealthier states like New York) to 77% (poorer states like Mississippi). The ACA set expansion population FMAP at 90%, but the reconciliation law reduces it to 80% by 2028. This reduction means states will pay a larger share of expansion costs, potentially leading some to restrict eligibility or benefits to manage budgets.
Why does per-capita Medicaid spending vary so much between states?
Per-capita spending ranges from about $4,000 in Mississippi to $14,000 in New York due to several factors: differences in provider reimbursement rates, scope of covered benefits (some states cover dental, vision, and long-term care more generously), cost of living variations, managed care vs fee-for-service mix, population health status, and the proportion of high-cost enrollees (elderly, disabled) vs lower-cost populations (healthy adults, children).