States have a lot of discretion in implementing the Affordable Care Act (ACA), and some are using that discretion to undermine expansion of insurance coverage under the law’s provisions. Twelve states, for example, could be characterized as “nonparticipating.” They have decided neither to expand Medicaid nor to play a role in establishing or governing their own insurance marketplaces, where individuals and small businesses can purchase coverage with federal subsidies. Some are actively fighting implementation by trying to block navigators from helping individuals find coverage under the ACA.
However, now that enrollment numbers are available, it is becoming clear that nonparticipating states have enjoyed only limited success in preventing the ACA from taking root in their jurisdictions. More than 3 million individuals have enrolled in a health plan through the marketplaces in nonparticipating states (see table). In seven of the 12 states, enrollment exceeded projections, including by more than 50 percent in Florida, Georgia, and North Carolina. Even Medicaid enrollment rose in half of the nonparticipating states because of the so-called “woodwork effect.” Nearly 400,000 individuals “came out of the woodwork” to get Medicaid coverage. They may have sought private insurance through federal marketplaces, and learned they were eligible for the existing Medicaid programs in nonparticipating states.
Affordable Care Act Enrollment in Nonparticipating States
| State | Marketplace Enrollment, October 2013- March 2014 |
Medicaid Growth, October 2013- March 2014 |
Marketplace Enrollment and Medicaid Growth, Percent of Population |
States' Uninsured Rate for Under-65 Population, Prior to Reform |
| Florida | 983,775 | 223,056 | 6.3% | 25% |
| North Carolina | 357,584 | 58,007 | 4.3% | 20% |
| Georgia | 316,543 | 98,834 | 4.3% | 22% |
| South Carolina | 118,324 | 53,644 | 3.7% | 19% |
| Oklahoma | 69,221 | 38,278 | 2.9% | 20% |
| Texas | 733,757 | 3,214 | 2.9% | 27% |
| Wisconsin | 139,815 | −10,651 | 2.3% | 12% |
| Louisiana | 101,778 | −7,904 | 2.1% | 22% |
| Missouri | 152,335 | −33,832 | 2.0% | 16% |
| Alaska | 12,890 | −1,179 | 1.7% | 20% |
| Alabama | 97,870 | −24,883 | 1.5% | 16% |
| Wyoming | 11,970 | −4,038 | 1.4% | 19% |
| TOTAL | 3,095,862 | 392,546 | 3.7% | 22% |
Note: "Nonparticipating states" are those not expanding Medicaid and wholly relying on the federal government for both the individual and small-business marketplaces.
Source: Enrollment data are from the Centers for Medicare and Medicaid Services, and include marketplace enrollment up until April 19 for those "in line" as of March 31. Data on population and the number of uninsured are from the Current Population Survey and for the years 2011 to 2012.
Florida is a case in point. Nearly 1 million Floridians got coverage through the state’s federally facilitated marketplace, and another 220,000 have enrolled in Medicaid since the ACA coverage provisions went live.
The populations of nonparticipating states also are benefiting from insurance provisions in the ACA that apply across the nation as a whole. Though some states are dragging their feet in implementing new insurance regulations, they cannot block the federal government from enforcing requirements that private plans cover dependents up to age 26, offer guaranteed issue and guaranteed renewability, cover preventive services, and abide by other consumer protections. These new national standards are undoubtedly enabling some citizens of nonparticipating states to gain new and/or more valuable health insurance coverage.
Of course, many more Americans would likely have gained coverage if all states actively supported the ACA’s implementation. Expanding Medicaid to 138 percent of poverty would have attracted many additional enrollees, particularly in the six nonparticipating states where Medicaid enrollment has stayed constant or fallen. In some jurisdictions, such as Alaska and Wyoming, enrollment in marketplaces has fallen short of expectations.
But the ACA’s impact on nonparticipating states is nevertheless significant. It is creating new facts on the ground that will make it more costly for elected officials from these states to vote for repealing or undermining the ACA. In every corner of the United States, the effects of the law’s coverage provisions are no longer abstract. They are visible in the faces of real people—men, women, and children, many from middle-class families—who are experiencing psychological, financial, and health advantages from the financial protection and access to care they now enjoy. As these folks show up at town meetings, and talk with their friends and neighbors, the ACA will become what its opponents have so long feared—part of the safety net that Americans rely on every day to protect them and their families from illness and its consequences.