Between the buzzing sounds of mosquitoes in the heat of a Charlotte summer, James had once stood tall, a man whose identity was firmly rooted in his roles as a devoted father, a loving husband, and a skilled mechanic. His days were filled with the satisfying hum of engines and the laughter of his young family, a symphony of love and purpose that had seemed as eternal as the rising sun. But when his daughter, Lily, was diagnosed with leukemia at the tender age of four, James felt the ground beneath his feet begin to crumble, the once-solid foundation of his life giving way to a chasm of fear and despair.

For months, James and his wife, Maria, existed in a world that had shrunk to the confines of the hospital walls, their every waking moment consumed by the desperate fight to save their little girl. They held vigil at her bedside, their hands clasped tightly around hers as she endured the ravages of chemotherapy, her tiny body wracked with pain and exhaustion. They sang to her, their voices trembling with emotion as they tried to soothe her to sleep, clinging to the hope that their love could somehow transcend the cruelty of fate. But despite their prayers and their tears, despite the countless hours spent bargaining with a God who seemed to have abandoned them, Lily slipped away just after her fifth birthday, leaving behind a void that could never be filled. ForJames, the loss was a wound that cut to the very core of his being, a pain so profound that it seemed to eclipse everything else. In the wake of his daughter’s death, he felt as though a part of himself had been ripped away, leaving behind a shell of a man who no longer knew how to navigate the world without her.

In the wake of their daughter’s death, James and Maria found themselves adrift in a sea of grief. They clung to each other at first, desperate for comfort and understanding. But as the weeks turned into months, Maria began to pull away, unable to bear the weight of her own sorrow, let alone her husband’s. She started staying out late, coming home with the scent of alcohol on her breath and a distant look in her eyes.

One day, James returned from work to find a note on the kitchen table. “I’m sorry,” Maria had written, “but I can’t do this anymore.” With those words, she was gone, leaving James alone in a house that now felt like a mausoleum, haunted by the ghosts of the family he had lost.

Desperate to numb the pain, James turned to the bottle. He started drinking heavily, showing up to work hungover and making careless mistakes. His boss, who had once been sympathetic to his situation, grew increasingly frustrated with his erratic behavior. One day, after a particularly bad bender, James was fired from the job he had held for over a decade.

Without a steady income, James soon fell behind on his bills. He lost his house, his car, and his sense of self-worth. He found himself living out of his old pickup truck, parking in quiet streets and sleeping fitfully in the cramped cab. He had never felt so alone, so utterly hopeless.

It was during this time that James first heard about Medicaid expansion in his state. He had always assumed that Medicaid was only for children, the elderly, or people with disabilities. But now, with his income reduced to zero and his mental health deteriorating rapidly, he realized that he might qualify for coverage.

Mustering what little energy he had left, James made his way to the local Medicaid office. The fluorescent lights buzzed overhead, casting a sickly glow on the worn linoleum floor. James felt a rush of shame as he filled out the application, his hands shaking as he tried to recall the details of his former life.

But to his surprise, the caseworker who reviewed his application was kind and understanding. She listened patiently as James poured out his story, offering words of encouragement and support. When she told him that he had been approved for Medicaid coverage, James felt a glimmer of hope for the first time in months.

With Medicaid, James was able to access the mental health services he so desperately needed. He started seeing a therapist who specialized in grief counseling, working through the tangled knot of emotions that had been weighing him down for so long. He also began attending regular check-ups with a primary care physician, who helped him manage the physical toll that his drinking and homelessness had taken on his body.

Slowly but surely, James began to rebuild his life. He found a job working part-time at a local grocery store, earning enough to rent a small studio apartment. He started attending Alcoholics Anonymous meetings, finding solace in the stories of others who had struggled with addiction and loss.

Through it all, Medicaid remained a constant source of support. Without the burden of medical bills or the fear of being denied care, James was able to focus on his recovery and his future. He knew that he would never fully heal from the loss of his daughter or the breakdown of his marriage, but he also knew that he was no longer alone in his struggle.

Just before James entered his local Medicaid office, in the early part of 2022, a fierce debate about people like him was raging in North Carolina’s legislature. For years, the state had been one of the few holdouts, resisting the call to expand Medicaid under the Affordable Care Act (ACA). But as the political winds began to shift, and the federal government dangled a tantalizing financial incentive, the once-unthinkable became possible for people like James.

Prior to the ACA, Medicaid eligibility was limited to specific groups, such as children, pregnant women, the elderly, and people with disabilities. The ACA sought to extend Medicaid coverage to a broader population, particularly low-income adults without dependent children, who were previously ineligible in most states. Under the ACA, states were given the option to expand their Medicaid programs to cover all adults under the age of 65 with incomes up to 138% of the federal poverty level. To incentivize states to participate, the federal government agreed to cover 100% of the costs of the newly eligible population for the first three years (2014-2016), gradually decreasing to 90% by 2020 and remaining at that level thereafter. States would be responsible forcovering the remaining share of the costs.

The expansion of Medicaid in North Carolina was a hard-fought battle, pitting Democratic Governor Roy Cooper against a Republican-controlled legislature. Cooper had long argued that expansion was a moral imperative, a way to provide health care to the state’s most vulnerable residents. But Republicans, led by powerful State Senator Phil Berger, had resisted, citing concerns about the long-term financial burden on the state.

The stalemate might have continued indefinitely, if not for a surprising turn of events. In 2022, the federal government offered a nearly $1.8 billion bonus to any state that expanded Medicaid, with no strings attached. For North Carolina, a state still reeling from the economic impact of the COVID-19 pandemic, the offer was too good to refuse.

Berger, once a staunch opponent of expansion, had a change of heart. In a stunning op-ed, he argued that the ACA was here to stay, and that refusing to accept the reality was only hurting North Carolinians and the state’s finances. With Berger’s support, the legislature passed a bill expanding Medicaid in March 2023, with broad bipartisan support.

The impact of expansion was immediate and profound. Overnight, more than 600,000 North Carolinians became eligible for Medicaid, many of them for the first time in their lives. The state’s Department of Health and Human Services, led by Secretary Kody Kinsley, worked tirelessly to ensure a smooth rollout, building alliances with healthcare providers and community organizations across the state.

The benefits of expansion were felt most acutely in rural North Carolina, where many residents struggled to access healthcare. With Medicaid expansion, rural hospitals and clinics had a new source of funding, allowing them to expand their services and hire more staff. Patients who had once foregone care due to cost could now see a doctor regularly, catching health problems before they became serious.

North Carolina’s experience with Medicaid expansion is just one chapter in a larger story that has played out across the country since the passage of the ACA in 2010. The decision to expand Medicaid, which was originally mandatory under the law, became optional for states after a 2012 Supreme Court ruling. Since then, the debate over expansion has been one of the most contentious issues in American politics, with far-reaching implications for healthcare access, state budgets, and electoral outcomes.

As of 2024, 40 states and the District of Columbia had expanded Medicaid under the ACA, extending coverage to millions of low-income adults who were previously ineligible for the program. The decision to expand Medicaid has remained deeply controversial in many states, often breaking down along partisan lines. The partisan divide over Medicaid expansion has had significant electoral consequences in recent years. In several states, including Virginia, Maine, and Kansas, Democratic candidates have campaigned successfully on a promise to expand Medicaid, often in the face of Republican opposition. In other states, such as Missouri and Oklahoma, voters have taken matters into their own hands, approving ballot measures to expand Medicaid even as their elected officials resisted.

Proponents of Medicaid expansion argued that it was a crucial step towards improving health outcomes and reducing disparities, while opponents raised concerns about the potential costs and long-term sustainability of the program. Despite the political debate, a growing body of peer-reviewed research has highlighted the positive impacts of Medicaid expansion on various aspects of healthcare and society.

One of the most significant benefits of Medicaid expansion has been its impact on health outcomes and access to care. A study on Federally Qualified Health Centers (FQHCs) in states that expanded Medicaid observed improved measures for blood pressure and glucose control over a five-year period, particularly for Black and Hispanic patients. Medicaid expansion has also been associated with an increase in viral suppression among patients with HIV, which is crucial for improving clinical outcomes and reducing transmission. Another study indicated that Medicaid expansion was, in fact, associated with a reduction in the rate of low birthweight births and preterm births, suggesting improved perinatal health outcomes. Access to timely cancer treatment has also improved in states that expanded Medicaid, with reduced racial disparities in the time to cancer treatment. Low-income adults in expansion states reported an increase in having a usual source of care and a decrease in foregoing needed care due to cost, compared to those in non-expansion states.

Medicaid expansion has had mixed effects on healthcare costs and hospital finances. Some studies have found that expanding Medicaid can help reduce overall healthcare costs by increasing access to preventive care and reducing the burden of uncompensated care on hospitals. However, other studies have indicated challenges for hospitals, such as increased operating expenses, as people with illness and “pent up demand” visited hospitals with more complex conditions.

Beyond its direct impact on health outcomes and healthcare costs, Medicaid expansion has had broader economic and social effects. During the COVID-19 pandemic, individuals in expansion states experienced a lower probability of reporting delayed care due to cost compared to those in non-expansion states, highlighting Medicaid’s role as a safety net program.

Medicaid expansion has also been shown to have positive effects on the economic outcomes of healthcare workers, particularly those in lower-wage positions. Medicaid expansion was associated with an increase in the probability of healthcare workers having health insurance and an increase in their average hourly wages. Despite the evidence supporting the benefits of Medicaid expansion, opponents have raised several concerns. One primary objection is the belief that expansion will place an undue financial burden on states. However, research suggests that these concerns may be overstated, with studies finding that the net fiscal impact of Medicaid expansion on state budgets has been positive in many cases, as savings and revenue gains outweigh the costs. States that expanded Medicaid experienced a lower increase in state Medicaid spending per enrollee compared to non-expansion states, indicating that expansion did not lead to run-away costs.

Another argument against Medicaid expansion is the notion that it will discourage work and create a disincentive for individuals to seek employment. However, available evidence does not support this claim, with studies finding no significant changes in employment or hours worked among low-income adults in states that expanded Medicaid compared to those that did not. Medicaid expansion was associated with an increase in the probability of being employed and an increase in weekly work hours among low-income adults.

In terms of the economic benefits of Medicaid, it is important to understand how the fiscal multiplier effect works. When the federal government increases its share of Medicaid costs, as it did during the Great Recession and the COVID-19 pandemic, it provides a direct stimulus to state economies. This is because the additional federal funding allows states to maintain or even expand their Medicaid programs without having to cut other areas of their budgets or raise taxes. In turn, this increased spending on healthcare services generates economic activity and creates jobs in the healthcare sector and beyond.

Medicaid also acts as an automatic stabilizer during economic downturns, meaning that enrollment and spending tend to increase as more people become eligible due to job losses and income reductions. This counter-cyclical nature of the program helps to mitigate the impact of recessions on vulnerable populations and supports economic recovery by maintaining consumer spending and preventing further job losses.

An increase in the unemployment rate would be expected to lead to an additional influx of enrollees in Medicaid and CHIP, with an associated increase in spending. This increased spending not only provides critical support for those who have lost their jobs and their health insurance but also acts as a stimulus for the broader economy.

As we learn from evidence around Medicaid expansion, it is clear that the program will continue to play a vital role in providing access to healthcare for millions of low-income Americans. The evidence presented in this chapter demonstrates the significant benefits ofMedicaid expansion, not only in terms of improved health outcomes and increased access to care but also in terms of broader economic and social impacts.

One of the key lessons from the Medicaid expansion experience is the importance of the federal-state partnership in ensuring the success of the program. The generous federal funding provided under the ACA, which covered costs of the newly eligible population for the first several years and continued to partially offset the costs over time, was a crucial factor in incentivizing states to expand their Medicaid programs. This funding structure allowed states to extend coverage to a broader population without placing an undue burden on their budgets.

Medicaid expansion also highlights the challenges of relying on a patchwork of state-level decisions to determine eligibility and benefits. The fact that several states have still not expanded Medicaid, despite the overwhelming evidence of its benefits, underscores the need for amore unified and equitable approach to ensuring access to healthcare for all Americans.

Looking beyond Medicaid expansion, the evidence presented in this chapter suggests that healthcare coverage can be a powerful stimulus for both healthcare and broader population health benefits. By providing access to preventive care, chronic disease management, and mental health services, Medicaid has been shown to improve health outcomes, reduce mortality rates, and lower healthcare costs in the long run. These benefits extend beyond the individual level, with studies showing that Medicaid expansion has had positive spillover effects on families, communities, and local economies.

The experience of Medicaid expansion during the COVID-19 pandemic has highlighted the critical role that the program plays as a safety net during times of crisis. As millions of Americans lost their jobs and their employer-sponsored health insurance, Medicaid enrollment surged, providing a lifeline for those who would otherwise have been left without access to care. The pandemic has also underscored the importance of addressing underlying health disparities and social determinants of health, which Medicaid is uniquely positioned to do through its comprehensive coverage and targeted outreach to vulnerable populations.

Looking to the future, there are several steps that policy makers can take to build on the successes of Medicaid expansion and ensure that the program continues to provide access to high-quality, affordable healthcare for all who need it. These include: encouraging the remaining states to expand Medicaid by providing additional financial incentives and technical assistance; strengthening the federal-state partnership by providing stable, long-term funding and reducing the administrative burden on states; addressing the social determinants of health through targeted interventions and partnerships with community-based organizations; investing in data collection and analysis to better understand the impact of Medicaid on health outcomes, healthcare costs, and economic indicators; and exploring innovative payment and delivery models that prioritize value-based care and population health. We will explore each of these issues in turn in the remaining chapters of this book.