Two years into the launch of the health insurance exchanges and Medicaid expansion under the Affordable Care Act, more than 20 states have not yet expanded Medicaid eligibility, missing out on billions of dollars in federal funding.

The combined Medicaid enrollment of the states that did not expand Medicaid eligibility actually decreased slightly from July 2013 to January 2014, according to Decision Resources Group data. But that’s not the case now.

From January 2014 to January 2015, Medicaid enrollment increased almost 11 percent nationwide. In the states that had not expanded Medicaid eligibility as of January 2015, Medicaid enrollment increased 4 percent.

That’s no surprise. Medicaid enrollment was expected to increase in the non-expansion states because of the so-called “woodwork effect,” in which individuals seeking subsidies through the health insurance exchange find out they are eligible but not enrolled in Medicaid.

A handful of non-expansion states did have decreases in Medicaid enrollment: Alabama’s Medicaid enrollment decreased 5 percent, Florida saw its enrollment drop 1 percent, Maine dropped 5 percent, Texas decreased almost 2 percent and Virginia had the biggest decrease at 7 percent.

South Carolina and North Carolina are among the non-expansion states with the largest enrollment increases, at 17 percent and 13 percent, respectively. Other non-expansion states with large increases in Medicaid enrollment include Idaho at 14 percent, Louisiana at 11 percent, and Georgia at 9 percent.

Although the decision whether to expand Medicaid eligibility is mostly political—with most states with Republican governors and/or Republican-controlled legislators refusing to expand eligibility—some GOP governors, such as Ohio’s John Kasich, have taken a more pragmatic approach. The financial implications are striking. According to a report from the Urban Institute and Robert Wood Johnson Foundation, states not expanding Medicaid will miss out on more than $423 billion in federal funding from 2013 to 2022. Hospitals in these states will not receive almost $168 billion in Medicaid reimbursements during the same timeframe.

Other states continue to slowly get on board with the expansion. In April 2015, Montana Gov. Steve Bullock signed a bill into law that expands Medicaid to residents earning at or below 138 percent of the federal poverty level, making about 70,000 Montanans eligible for Medicaid. However, the expansion has not taken effect. The state must seek a waiver from the federal government to implement the program because it diverges from traditional Medicaid. In July 2015, Alaska Gov. Bill Walker announced he would expand Medicaid without legislative approval, but the Republican-controlled legislature is sure to give him a fight.

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