Health Affairs September 15, 2025
Introduction
As of 2025, 40 states and the District of Columbia have implemented expansions of Medicaid eligibility under the Affordable Care Act (ACA).1 A large body of research has found that these expansions are associated with improved health care coverage, access to care, and health outcomes.2 The One Big Beautiful Bill Act (OBBBA) recently passed by Congress introduces significant changes to Medicaid expansion, including a requirement for states to condition enrollment on working or participating in other qualifying activities.3 Estimates from the Congressional Budget Office suggest that this work reporting requirement will result in coverage losses for millions of expansion enrollees, in large part due to the administrative barriers enrollees will face attempting to report they are in compliance.4
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