Medicaid Expansion: Busting Budgets, Bankrupting Taxpayers, and Displacing the Truly Needy

Overview

Nationwide, the Medicaid program is in shambles. The program was designed to provide a safety net for truly needy Americans—such as seniors, individuals with disabilities, low-income children, and pregnant women.¹

But sadly, the Medicaid program has veered off course and program priorities have shifted. ObamaCare expansion opened the door to covering a new class of able-bodied, working-age adults on Medicaid.² States across the country took the bait, opting to expand their Medicaid programs based on empty promises, false assumptions, and faulty data.³

Today, these states are facing an enrollment and budget crisis—leaving lawmakers with their hands tied as their Medicaid programs consume limited resources.⁴ Meanwhile, the truly needy—those the program was designed to serve—have been pushed to the back of the line.

Non-expansion states should take note of these experiences and learn from the mistakes of their neighbors to preserve the integrity of their Medicaid programs and protect the truly needy.

Medicaid enrollment has skyrocketed

In 2023, total Medicaid enrollment hit a whopping 100 million—a record high.⁵ A primary driver of the enrollment explosion over the last decade has been able-bodied adults—especially those made eligible through ObamaCare expansion.⁶ Advocates of expansion have continually claimed that enrollment would be low and predictable, but the reality is that enrollment has been of out of control.

Faulty data and politically motivated assumptions have led to enrollment projections that were both inaccurate and misleading—and unfortunately states have paid the price.⁷ Initial estimates in expansion states claimed that only 6.5 million able-bodied adults would ever be enrolled once Medicaid expansion went into effect.⁸ The left-leaning Kaiser Family Foundation (KFF) also produced projections and estimated that only 8.6 million able-bodied adults would enroll in expansion states.⁹

Predictably, these estimates missed the mark, as the so-called experts drastically underestimated how explosive expansion enrollment would be. According to the most recently available data, Medicaid expansion enrollment skyrocketed to more than 23 million in 2023—nearly four times higher than state estimates and three times higher than KFF estimates.¹⁰

While the enrollment situation is dire, it is only part of the story, as soaring enrollment has led to massive cost overruns that are bankrupting states and taxpayers. 

Expansion costs have been exploding

Even before states were given the option to expand, the Medicaid program was typically the largest and fastest-growing line item in state budgets—as Medicaid spending more than doubled between 2000 and 2013.¹¹ For states, Medicaid expansion only exacerbated an already rapidly growing problem.

Unfortunately, the situation has only become more dire. Faulty enrollment assumptions led to even worse cost projections for states planning to expand their Medicaid programs. Since 2014, Medicaid expansion has cost taxpayers more than twice what state officials initially promised.^12-51 In 2023 alone, Medicaid expansion cost taxpayers $139 billion—a cost overrun of nearly 180 percent when compared to states’ projected cost of less than $50 billion.^52-53

All told, expansion states cost taxpayers more than $1 trillion between 2014 and 2023— $574 billion more than expected.⁵⁴ States carried at least $54 billion of those costs, despite advocates claiming that expansion would somehow save states money.⁵⁵ And while some proponents may blame the pandemic for these bloated costs, that could not be further from the truth, as expansion costs were already more than double what was projected through 2019.⁵⁶

States are facing an enrollment and budget crisis

All states are dealing with Medicaid expansion woes, but some states have been hit harder than others. As expansion states have seen colossal enrollment overruns and decimated budgets, the truly needy have been pushed to the back of the line.

ARKANSAS

The state projected that only 215,000 able-bodied adults could be expected to participate in the newly expanded Medicaid program.⁵⁹ Enrollment quickly smashed those projections and costs have since spiraled out of control. By 2023, Arkansas’s Medicaid expansion had cost taxpayers more than $18 billion—exceeding state estimates by 112 percent.⁶⁰

CALIFORNIA

California has been plagued by out-of-control costs as well. By 2023, nearly one in every three dollars in the state budget went to Medicaid.⁶³ State officials estimated that expansion would be accompanied by a price tag of nearly $55 billion by 2023, but actual costs have surpassed $203 billion—a cost overrun of 271 percent.^64-65

ILLINOIS

State officials also projected that expansion costs would total a little more than $18 billion by 2023.⁷⁰ But the enrollment surge drove costs well beyond that, as actual spending tallied in at $43 billion—more than doubling projections and an increase of 136 percent.⁷¹

LOUISIANA

Regrettably for taxpayers, these enrollment overruns have driven spending through the roof. State officials projected that expansion spending would cost $9.5 billion by 2023, but actual spending was more than triple state estimates, reaching nearly $29 billion.⁷⁶ Medicaid spending now accounts for 35 percent of the state budget, more than the state spends on K-12 education and higher education combined.⁷⁷

OHIO

As enrollment has spiraled out-of-control, so has spending. State officials estimated that expansion spending would reach $25 billion by 2023, but actual spending tallied in at roughly $46 billion—a cost overrun of 83 percent.^82-83 This is bad news for taxpayers, as more than half of the state’s general revenue budget now goes to the Medicaid program—one of the highest percentages nationwide.⁸⁴

WEST VIRGINIA

Sadly, the cost estimates did not fare better. State officials projected that expansion spending would cost taxpayers roughly $5.2 billion by 2023.⁸⁹ But after a decade of expansion, actual spending had catapulted to $9.2 billion—an overrun of 76 percent.⁹⁰ As expansion spending has ravaged the state, Medicaid now accounts for nearly 30 percent of the entire state budget—more than K-12 education and higher education combined.⁹¹

Non-expansion states should read the writing on the wall

As non-expansion states grapple with the decision of whether to expand Medicaid, state officials should heed the warning signs exhibited by the states that ultimately were led down the wrong path.

If the remaining non-expansion states opted to expand their Medicaid programs, they could expect to see enrollment skyrocket well beyond 11 million able-bodied adults—blowing past the shaky projections of states, KFF, and the Urban Institute, which have been consistently wrong since the beginning of expansion.⁹²

This enrollment surge that would be unleashed by newly eligible able-bodied adults would also generate massive new costs for taxpayers—to the tune of nearly $670 billion.⁹³ Medicaid expansion nationwide has already cost taxpayers more than double what was promised, and the experience of non-expansion states would be no different.

The Bottom Line: Non-expansion states must continue to reject the false promises of Medicaid expansion.

The debate over whether non-expansion states should implement drastic changes to their Medicaid programs rages on, but every metric has proven time and time again that Medicaid expansion has been a complete disaster in states that have expanded.

By 2023, the number of able-bodied adults enrolled in Medicaid expansion nationwide reached nearly 25 million—completely shattering the projections of so-called experts.⁹⁴ This enrollment surge has led to expansion spending surpassing $1 trillion since its inception.⁹⁵

If the remaining non-expansion states were to expand their Medicaid programs, they could expect more of the same: busted budgets, skyrocketing enrollment, and a complete departure from the Medicaid program’s original purpose.

REFERENCES

1 Centers for Medicare and Medicaid Services, “Program history,” U.S. Department of Health and Human Services (2022), https://www.medicaid.gov/about-us/program-history/index.html.

2 Jonathan Bain, “Busted budgets and skyrocketing enrollment: Why states should reject the false promises of Medicaid expansion,” Foundation for Government Accountability (2023), https://thefga.org/research/states-should-reject-false-promises-of-medicaid-expansion.

3 Ibid.

4 Ibid.

5 Ibid.

6 Ibid.

7 Ibid.

8 Ibid.

9 Ibid.

10 Medicaid Budget and Expenditure System, “Medicaid enrollment – New adult group,” Centers for Medicare and Medicaid Services (2024), https://data.medicaid.gov/dataset/6c114b2c-cb83-559b-832f-4d8b06d6c1b9.

11 Jonathan Ingram and Nicholas Horton, “A budget crisis in three parts: How ObamaCare is bankrupting taxpayers,” Foundation for Government Accountability (2018), https://thefga.org/research/budget-crisis-three-parts-obamacare-bankrupting-taxpayers.

12 Authors’ calculations based upon data provided by the U.S. Department of Health and Human Services and state Medicaid agencies on projected expenditures and actual expenditures for Medicaid expansion enrollees. Projected spending has been extended to 2023 in states with projections ending before 2023.

13 Alaska initially projected that Medicaid expansion would cost less than $1.6 billion in the first six years, with projections ending in 2021. Actual costs for this period totaled more than $3.6 billion. These projected costs were extended to 2023 by applying the state’s projected 2019-2021 growth factors for enrollment and per capita expenditures.

14 Arizona initially projected that unfreezing Proposition 204 enrollment and further expanding eligibility under ObamaCare would cost $5.9 billion in the first four fiscal years, with projections ending in 2017. Actual costs for this period totaled nearly $8.2 billion. These projected costs were extended to 2023 by applying the state’s projected 2015-2017 growth factors for expenditures, disaggregated by parental status and income level.

15 Arkansas initially projected that Medicaid expansion would cost $5.9 billion in the first eight fiscal years, with projections ending in 2021. These projections did not adjust for inflation, but were presented in “real” 2012 dollars. Adjusting the annual projected costs by annual June inflation rates, the nominal projected cost for expansion would total $6.4 billion. Actual costs for this period totaled nearly $12.8 billion. These projected costs were extended to 2023 by applying the state’s projected 2019-2021 growth factors for expenditures, disaggregated enrollment group.

16 California initially projected that Medicaid expansion would cost $34.7 billion in the first seven fiscal years, with projections ending in 2020. Actual costs for this period totaled nearly $126.4 billion. These projected costs were extended to 2023 by applying the state’s projected 2015-2020 growth factors for enrollment and per capita expenditures.

17 Colorado initially projected that Medicaid expansion would cost $2.2 billion in the first three fiscal years, with projections ending in 2016. Actual costs for this period totaled more than $3.1 billion. These projected costs were extended to 2023 by applying the state’s projected 2014-2016 growth factors for per capita expenditures, disaggregated by enrollment category and payment type.

18 Connecticut did not produce total cost estimates prior to expanding Medicaid.

19 Delaware did not produce total cost estimates prior to expanding Medicaid and had a pre-ObamaCare Medicaid expansion covering most of the potential expansion population. Only 15 percent of the expansion population in Delaware are classified as newly eligible, as the remainder qualified under the state’s pre-ObamaCare rules.

20 Hawaii initially projected that Medicaid expansion would cost $656 million in the first five years, with projections ending in 2018. Actual costs for this period totaled nearly $2.1 billion. These projected costs were extended to 2023 by applying the state’s projected 2016-2018 growth factors for enrollment and per capita expenditures.

21 Idaho initially projected that Medicaid expansion would cost $1.5 billion in the first four years, with projections ending in 2023. Actual costs for this period totaled nearly $2.4 billion.

22 Illinois initially projected that Medicaid expansion would cost $12.7 billion in the first 7 years, with projections ending in 2020. Actual costs for this period totaled nearly $24.8 billion. These projected costs were extended to 2023 by applying the state’s projected 2018-2020 growth factors for enrollment and per capita expenditures.

23 Indiana initially projected that Medicaid expansion would cost less than $16.2 billion in the first seven fiscal years, with projections ending in 2020. Actual costs for this period totaled nearly $16.3 billion. Indiana’s initial projections reflected reaching near full enrollment for the first six months, making its total overrun over the first seven fiscal years seem relatively low. However, the state began to exceed annual projected costs in within three years. These projected costs were extended to 2023 by applying the state’s projected 2018-2020 growth factors for expenditures, disaggregated by prior insurance status.

24 Iowa initially projected that Medicaid expansion would cost less than $5 billion in the first seven fiscal years, with projections ending in 2020. Actual costs for this period totaled more than $10.9 billion. These projected costs were extended to 2023 by applying the state’s projected 2016-2020 growth factors for expenditures.

25 Kentucky initially projected that Medicaid expansion would cost less than $10.1 billion in the first eight fiscal years, with projections ending in 2021. Actual costs for this period totaled nearly $22.6 billion. These projected costs were extended to 2023 by applying the state’s projected 2017-2021 growth factors for expenditures.

26 Louisiana initially projected Medicaid expansion would cost $5.6 billion in the first five years and $16 billion over the first ten years, but did not produce annual estimates. Applying the state’s assumed growth factors for expenditures, eligible populations, and take-up rates to create annualized projections, the state’s projected cost for the first seven years of Medicaid expansion totaled approximately $9.5 billion. Actual costs totaled more than $15.3 billion in the first five years and more than $28.9 billion in the first seven years.

27 Maine initially projected Medicaid expansion would cost less than $1.9 billion in the first four fiscal years, with projections ending in 2021. Actual costs for this period totaled nearly $1.6 billion. Maine’s initial projections reflected reaching full enrollment on day 1 of expansion, depressing its total overrun over the first four fiscal years. However, the state began to exceed annual projected costs in within that period. These projected costs were extended to 2023 by applying the state’s projected 2018-2021 growth factors for expenditures, disaggregated by eligibility group.

28 Maryland initially projected Medicaid expansion would cost $4.8 billion over the first seven fiscal years, with projections ending in 2020. Actual costs for this period totaled more than $15.6 billion. These projected costs were extended to 2023 by applying the state’s projected 2017-2020 growth factors for expenditures, disaggregated by eligibility group.

29 Massachusetts did not produce total cost estimates prior to expanding Medicaid and had a pre-ObamaCare Medicaid expansion covering all of the potential expansion population. None of expansion population in Massachusetts are classified as newly eligible.

30 Michigan initially projected Medicaid expansion would cost less than $31.1 billion in the first 33 fiscal quarters, with projections ending in 2023. Actual costs for this period totaled more than $39.6 billion.

31 Minnesota initially produced total cost estimates prior to expanding Medicaid, but has since deleted all records related to those estimates. Because those records no longer exist and were not archived, Minnesota has been excluded from this analysis.

32 Missouri initially projected that Medicaid expansion would cost $2.1 billion in the first seven fiscal quarters. Actual costs for this period totaled more than $3.1 billion.

33 Montana initially projected that Medicaid expansion would cost $1 billion in the first four years, with projections ending in 2019. Actual costs for this period totaled nearly $2.3 billion. These projected costs were extended to 2023 by applying the state’s projected 2017-2019 growth factors for enrollment and per capita expenditures.

34 Nebraska initially projected that Medicaid expansion would cost $931 million in the first 11 fiscal quarters. However, expansion began much later than the initial projections expected. Applying the state’s projected growth factors for per capita expenditures to trend forward to the 2021-2023 period, the adjusted projection for this period was less than $1.1 billion. Actual costs for this period totaled more than $1.7 billion.

35 Nevada initially projected Medicaid expansion would cost $1.9 billion in the first seven fiscal years, with projections ending in 2020. Actual costs for this period totaled more than $7.2 billion. These projected costs were extended to 2023 by applying the state’s projected 2017-2019 growth factors for enrollment and per capita expenditures, disaggregated by eligibility category.

36 New Hampshire initially projected Medicaid expansion would cost less than $1.6 billion in the first six fiscal years. Actual costs for this period totaled more than $2 billion. These projected costs were extended to 2023 by applying the state’s projected growth factors for eligible populations, takeup rates, and per capita expenditures.

37 New Jersey did not produce total cost estimates prior to expanding Medicaid. State officials only estimated the state and local share of expansion costs, and only during fiscal years 2014 and 2015, when federal taxpayers covered 100 percent of the cost.

38 New Mexico initially projected Medicaid expansion would cost less than $5.1 billion in the first seven fiscal years, with projections ending in 2020. Actual costs for this period totaled nearly $8.8 billion. These projected costs were extended to 2023 by applying the state’s projected 2018-2020 growth factors for expenditures.

39 New York initially projected Medicaid expansion would cost $285 million per year, but did not produce annual projections. Actual costs for the first year alone totaled nearly $441 million. These projected costs were extended to 2023 by applying the state’s microsimulation model’s projected 2016-2022 growth factors for expenditures.

40 North Dakota initially projected Medicaid expansion would cost less than $544 million in the first seven years, with projections ending in 2020. Actual costs for this period totaled nearly $1.8 billion. These projected costs were extended to 2023 by applying the state’s projected 2017-2020 growth factors for expenditures.

41 Ohio initially projected Medicaid expansion would cost less than $15.5 billion in the first seven fiscal years, with projections ending in 2020. Actual costs for this period totaled nearly $24.9 billion. These projected costs were extended to 2023 by applying the state’s projected 2018-2020 growth factors for expenditures.

42 Oklahoma initially projected Medicaid expansion would cost less than $2.9 billion in the first two years. Actual costs for this period totaled nearly $4.2 billion.

43 Oregon initially projected Medicaid expansion would cost less than $10.3 billion in the first seven fiscal years, with projections ending in 2020. Actual costs for this period totaled more than $16.7 billion. These projected costs were extended to 2023 by applying the state’s projected 2017-2020 growth factors for enrollment and per capita expenditures.

44 Pennsylvania initially projected Medicaid expansion would cost less than $19.3 billion over the first eight fiscal years, with projections ending in 2021. Actual costs for this period totaled more than $39.2 billion. These projected costs were extended to 2023 by applying the state’s projected 2018-2021 growth factors for expenditures, disaggregated by eligibility category.

45 Rhode Island initially projected Medicaid expansion would cost less than $779 million in the first five fiscal years, with projections ending in 2018. Actual costs for this period totaled nearly $1.9 billion. These projected costs were extended to 2023 by applying the state’s projected 2017-2018 growth factors for expenditures.

46 South Dakota expanded Medicaid effective July 2023 and did not have actual expenditures data available at the time of this report.

47 Utah initially projected Medicaid expansion would cost $1.5 billion in the first four fiscal years. Actual costs for this period totaled more than $2.8 billion.

48 Vermont did not produce total cost estimates prior to expanding Medicaid and had a pre-ObamaCare Medicaid expansion covering all of the potential expansion population. None of expansion population in Vermont are classified as newly eligible.

49 Virginia initially projected Medicaid expansion would cost less than $13.1 billion in the first five fiscal years. Actual costs for this period totaled more than $19.8 billion.

50 Washington initially projected Medicaid expansion would cost $11 billion in the first seven years, with projections ending in 2020. Actual costs for this period totaled more than $24.7 billion. These projected costs were extended to 2023 by applying the state’s projected 2018-2020 growth factors for enrollment and per capita expenditures, disaggregated by eligibility category.

51 West Virginia initially projected Medicaid expansion would cost $5.4 billion in the first ten fiscal years. Actual costs for this period totaled more than $9.2 billion.

52 Authors’ calculations based upon data provided by the U.S. Department of Health and Human Services and state Medicaid agencies on projected expenditures and actual expenditures for Medicaid expansion enrollees. Projected spending has been extended to 2023 in states with projections ending before 2023.

53 Other federal sources put total Medicaid expansion spending even higher in 2023 than reported here. The U.S. Department of Health and Human Services’ financial management report for fiscal year 2023, for example, reports total Medicaid expenditures for newly eligible expansion enrollees at $150 billion. However, this total includes data from Connecticut, Delaware, Minnesota, and New Jersey, while those states have been excluded from this report for having no publicly-available expenditure projections, and that report utilizes the federal October through September fiscal year, while this report presents a July through June fiscal year, the budget cycle used by all expansion states other than Michigan and New York. See, e.g., Centers for Medicare and Medicaid Services, “Financial management report for fiscal year 2023,” U.S. Department of Health and Human Services (2024), https://www.medicaid.gov/medicaid/financial-management/downloads/financial-management-report-fy2023.zip.

54 Authors’ calculations based upon data provided by the U.S. Department of Health and Human Services and state Medicaid agencies on projected expenditures and actual expenditures for Medicaid expansion enrollees. Projected spending has been extended to 2023 in states with projections ending before 2023.

55 Ibid.

56 Ibid.

57 Jonathan Bain, “Arkansas’s Medicaid meltdown: How bad policies have led to busted budgets and skyrocketing enrollment,” Foundation for Government Accountability (2023), https://thefga.org/research/arkansas-medicaid-meltdown-busted-budgets-skyrocketing-enrollment.

58 Ibid.

59 Jonathan Ingram and Nicholas Horton, “The ObamaCare expansion enrollment explosion,” Foundation for Government Accountability (2015), https://thefga.org/research/the-obamacare-expansion-enrollment-explosion.

60 Arkansas initially projected that Medicaid expansion would cost $5.9 billion in the first eight fiscal years, with projections ending in 2021. These projections did not adjust for inflation, but were presented in “real” 2012 dollars. Adjusting the annual projected costs by annual June inflation rates, the nominal projected cost for expansion would total $6.4 billion. Actual costs for this period totaled nearly $12.8 billion. These projected costs were extended to 2023 by applying the state’s projected 2019-2021 growth factors for expenditures, disaggregated enrollment group. Extending these projections, Medicaid expansion was expected to cost less than $8.5 billion by the end of fiscal year 2023. Actual costs for this period totaled more than $18 billion.

61 Jonathan Ingram and Nic Horton, “ObamaCare expansion enrollment is shattering projections: Taxpayers and the truly needy will pay the price,” Foundation for Government Accountability (2016), https://thefga.org/research/obamacare-expansion-enrollment-is-shattering-projections-2. 

62 Centers for Medicare and Medicaid Services, “April – June 2023 Medicaid MBES enrollment (updated May 2024),” U.S. Department of Health and Human Services (2024), https://www.medicaid.gov/media/national-medicaid-chip-program-information/downloads/apr-jun-2023-medicaid-mbes-enrollment.xlsx.

63 Brian Sigritz et al., “2023 state expenditure report,” National Association of State Budget Officers (2023), https://higherlogicdownload.s3.amazonaws.com/NASBO/9d2d2db1-c943-4f1b-b750-0fca152d64c2/UploadedImages/SER%20Archive/2023_State_Expenditure_Report-S.pdf.

64 California initially projected that Medicaid expansion would cost $34.7 billion in the first seven fiscal years, with projections ending in 2020. These projected costs were extended to 2023 by applying the state’s projected 2015-2020 growth factors for enrollment and per capita expenditures. Extending these projections, Medicaid expansion was expected to cost less than $54.8 billion by the end of fiscal year 2023.

65 Actual costs for the first seven fiscal years totaled nearly $126.4 billion, while the actual cost through fiscal year 2023 totaled more than $203 billion. 66 Jonathan Ingram and Nicholas Horton, “A budget crisis in three parts: How ObamaCare is bankrupting taxpayers,” Foundation for Government Accountability (2018), https://thefga.org/research/budget-crisis-three-parts-obamacare-bankrupting-taxpayers.

67 Ibid.

68 Ibid.

69 Centers for Medicare and Medicaid Services, “April – June 2023 Medicaid MBES enrollment (updated May 2024),” U.S. Department of Health and Human Services (2024), https://www.medicaid.gov/media/national-medicaid-chip-program-information/downloads/apr-jun-2023-medicaid-mbes-enrollment.xlsx.

70 Illinois initially projected that Medicaid expansion would cost $12.7 billion in the first 7 years, with projections ending in 2020. These projected costs were extended to 2023 by applying the state’s projected 2018-2020 growth factors for enrollment and per capita expenditures. Extending these projections, Medicaid expansion was expected to cost less than $18.2 billion by the end of fiscal year 2023.

71 Actual costs for the first seven years totaled nearly $24.8 billion, while the actual cost through fiscal year 2023 totaled $43 billion.

72 Louisiana Executive Order JBE-16-01 (2016), https://gov.louisiana.gov/assets/ExecutiveOrders/JBE1601.pdf.

73  Jonathan Ingram and Nic Horton, “ObamaCare expansion enrollment is shattering projections: Taxpayers and the truly needy will pay the price,” Foundation for Government Accountability (2016), https://thefga.org/research/obamacare-expansion-enrollment-is-shattering-projections-2.

74 Ibid.

75 Ibid.

76 Louisiana initially projected Medicaid expansion would cost $5.6 billion in the first five years and $16 billion over the first ten years, but did not produce annual estimates. Applying the state’s assumed growth factors for expenditures, eligible populations, and take-up rates to create annualized projections, the state’s projected cost for the first seven years of Medicaid expansion totaled approximately $9.5 billion. Actual costs totaled more than $15.3 billion in the first five years and more than $28.9 billion in the first seven years.

77 Brian Sigritz et al., “2023 state expenditure report,” National Association of State Budget Officers (2023), https://higherlogicdownload.s3.amazonaws.com/NASBO/9d2d2db1-c943-4f1b-b750-0fca152d64c2/UploadedImages/SER%20Archive/2023_State_Expenditure_Report-S.pdf.

78 Jonathan Ingram and Nicholas Horton, “A budget crisis in three parts: How ObamaCare is bankrupting taxpayers,” Foundation for Government Accountability (2018), https://thefga.org/research/budget-crisis-three-parts-obamacare-bankrupting-taxpayers.

79 Ibid.

80 Ibid.

81 Ibid.

82 Ohio initially projected Medicaid expansion would cost less than $15.5 billion in the first seven fiscal years, with projections ending in 2020. These projected costs were extended to 2023 by applying the state’s projected 2018-2020 growth factors for expenditures. Extending these projections, Medicaid expansion was expected to cost $25 billion by the end of fiscal year 2023.

83 Actual costs for the first seven fiscal years totaled nearly $24.9 billion, while the actual cost through fiscal year 2023 totaled $45.8 billion.

84 Legislative Budget Office, “Budget in brief: Main operating budget,” Ohio Legislative Service Commission (2023), https://www.lsc.ohio.gov/assets/legislation/135/hb33/en0/files/hb33-budget-in-brief-as-enacted-135th-general-assembly.pdf.

85 Jonathan Ingram and Nicholas Horton, “A budget crisis in three parts: How ObamaCare is bankrupting taxpayers,” Foundation for Government Accountability (2018), https://thefga.org/research/budget-crisis-three-parts-obamacare-bankrupting-taxpayers.

86 Jonathan Ingram and Nic Horton, “ObamaCare expansion enrollment is shattering projections: Taxpayers and the truly needy will pay the price,” Foundation for Government Accountability (2016), https://thefga.org/research/obamacare-expansion-enrollment-is-shattering-projections-2

87 Centers for Medicare and Medicaid Services, “April – June 2023 Medicaid MBES enrollment (updated May 2024),” U.S. Department of Health and Human Services (2024), https://www.medicaid.gov/media/national-medicaid-chip-program-information/downloads/apr-jun-2023-medicaid-mbes-enrollment.xlsx.

88 Authors’ calculations based upon data provided by the U.S. Department of Health and Human Services on the number of Medicaid enrollees in West Virginia in June 2023, disaggregated by enrollment category, and data provided by the U.S. Department of Commerce on the number of residents in West Virginia.

89 West Virginia initially projected Medicaid expansion would cost $5.4 billion in the first ten fiscal years.

90 Actual costs for the first ten fiscal years totaled more than $9.2 billion.

91 Brian Sigritz et al., “2023 state expenditure report,” National Association of State Budget Officers (2023), https://higherlogicdownload.s3.amazonaws.com/NASBO/9d2d2db1-c943-4f1b-b750-0fca152d64c2/UploadedImages/SER%20Archive/2023_State_Expenditure_Report-S.pdf.

92 Jonathan Bain, “Busted budgets and skyrocketing enrollment: Why states should reject the false promises of Medicaid expansion,” Foundation for Government Accountability (2023), https://thefga.org/research/states-should-reject-false-promises-of-medicaid-expansion.

93 Ibid.

94 Authors’ calculations based upon data provided by the U.S. Department of Health and Human Services on Medicaid enrollment in June 2023, disaggregated by eligibility category. In June 2023, total “Group VIII” enrollment reached 24.5 million adults, including able-bodied adults receiving enhanced federal matching funds in states that had expanded eligibility prior to ObamaCare. Those deemed “newly eligible” totaled more than 19.7 million. See, e.g., Centers for Medicare and Medicaid Services, “April – June 2023 Medicaid MBES enrollment (updated May 2024),” U.S. Department of Health and Human Services (2024), https://www.medicaid.gov/media/national-medicaid-chip-program-information/downloads/apr-jun-2023-medicaid-mbes-enrollment.xlsx.

95 Authors’ calculations based upon data provided by the U.S. Department of Health and Human Services on Medicaid expenditures between January 2014 and June 2023, disaggregated by eligibility category. Over this period, “Group VII” expenditures totaled more than $1 trillion, including costs for able-bodied adults receiving enhanced federal matching funds in states that had expanded eligibility prior to ObamaCare. Expenditures for those deemed “newly eligible” totaled more than $809 billion over this period.