Georgia governor-elect Keisha Lance Bottoms celebrated her victory on election night by declaring that the outcome belonged to caregivers who cannot afford healthcare and desperately need the state to finally expand Medicaid.
Bottoms joined fellow Democratic gubernatorial victors Cindy Holscher in Kansas, Gina Hinojosa in Texas, and David Crowley in Wisconsin in anchoring their recent campaigns on the promise to widen government health insurance access for low-income adults. A complete expansion across these four states could extend coverage to more than one million residents, according to data from KFF.
Achieving that expansion presents steep political and fiscal roadblocks. A budgetary law enacted in Washington eliminated federal financial incentives for states choosing to adopt the expansion while slapping strict work requirements and funding caps on participating jurisdictions.
“It’s a very complex situation,” Caylee Noggle, former Georgia Medicaid director and current president of the Georgia Hospital Association, told CNN.
Forty states and Washington, D.C., have expanded Medicaid since the 2010 Affordable Care Act became law, with North Carolina marking the most recent addition in 2023. Meanwhile, Georgia, Wisconsin, and eight other states have consistently rejected full eligibility expansion.
Federal finances changed dramatically when the internal policy package championed by President Donald Trump rescinded expansion bonuses. The legislation also restricted federal funds that hospitals rely on to treat high volumes of Medicaid patients, hitting expansion states harder than non-expansion states.
Lawmakers in Wisconsin face intense scrutiny over those funding limitations. The Wisconsin Hospital Association estimates that full Medicaid expansion could jeopardize hundreds of millions of dollars in federal support flowing into the state.
“These are going to be difficult conversations,” Bobby Peterson, a Madison-based benefits attorney, told CNN.
Crowley backed full Medicaid expansion early in his campaign before later suggesting the state might open its existing partial expansion plan to any interested resident. His campaign did not respond to specific inquiries regarding his post-inauguration legislative agenda.
States that broaden eligibility receive elevated federal matching funds for newly enrolled populations, easing pressure on rural hospitals threatened with closure. At the same time, state governments must secure local revenue to cover their matching share.
“It’s a very complicated math problem,” Lawson Mansell, senior health policy analyst at the Niskanen Center, told CNN.
| State | Governor-Elect | Legislative Control | Estimated Uninsured Impacted |
|---|---|---|---|
| Georgia | Keisha Lance Bottoms | Divided / Republican lean | Over 1 million (combined total) |
| Kansas | Cindy Holscher | Republican majority | Included in regional totals |
| Texas | Gina Hinojosa | Split (Rep. Senate, Dem. House) | Over four million ACA enrollees |
| Wisconsin | David Crowley | Democratic governor, GOP legislature | Hundreds of millions in hospital funds |
The federal policy shift also mandates that beneficiaries prove they work or complete at least 80 hours monthly in qualifying activities. Following intense state pushback, the White House granted a six-month delay on November 13, pushing back enforcement from the initial January start date.
“Even if a state adopts the expansion, unfortunately, it is very possible that many people will remain uninsured because of all these changes that essentially add more red tape,” Edwin Park, research professor at the Georgetown University Center for Children and Families, told CNN.
In Texas, where over four million residents selected Affordable Care Act marketplace plans for 2026, critics have long warned against shifting enrollees into government rolls. Former U.S. Representative Beto O’Rourke said that Hinojosa’s legislative background makes healthcare a clear priority.
“The stories of people she met across the state who were struggling to get by without healthcare deeply moved her,” O’Rourke told CNN. “It’s clear this is a top priority for her.”
Despite Democrats winning the Texas governorship and taking the state House, Republicans retain a firm grip on the state Senate.
“We’ve gone multiple legislative sessions without even a serious conversation about expanding Medicaid,” Henderson told CNN. “There was interest in the House, but never any appetite in the Senate.”
In Kansas, Holscher secured a narrow victory to succeed outgoing Democratic Governor Laura Kelly, whose expansion proposals repeatedly stalled. Although Republicans preserved majorities in both legislative chambers this November, Democrats successfully broke the GOP supermajority in the state House.
“I’ve been doing this long enough to have seen several different iterations of the Kansas House,” April Holman, executive director of the nonprofit Alliance for a Healthy Kansas, told CNN. “This is the most promising group we’ve had in a very, very long time.”
