- 25 million Americans remain uninsured in 2026 — a 7.5% rate, down from 16% in 2013, with the ACA keeping approximately 20 million insured who would otherwise lack coverage.
- 14 states have still not expanded Medicaid, despite the federal government covering 90% of expansion costs — leaving their lowest-income residents in a coverage gap where they earn too much for traditional Medicaid but too little for subsidized marketplace plans.
- Multiple states that rejected legislative expansion have since passed it via citizen ballot measure — including Idaho, Montana, Oklahoma, and Missouri — suggesting significant public support even in red states.
- Texas (18.4% uninsured, ~1.5M in coverage gap) and Florida (no expansion) together account for the largest share of the remaining uninsured problem — both states with competitive 2026 Senate and House races.
The 14 Medicaid Non-Expansion States
These states have declined federal Medicaid cuts funding, leaving their residents without coverage in the "Medicaid gap" — earning too much for traditional Medicaid but too little for marketplace subsidies. Federal matching rate for expansion: 90% federal / 10% state.
| State | Gov. Party | Uninsured Rate | Gap Population | Expansion Poll |
|---|---|---|---|---|
| Texas | R | 18.4% | ~1.5M | 62% support expansion |
| Florida | R | 13.2% | ~830k | 64% support expansion |
| Georgia | R | 14.7% | ~380k | 67% support expansion |
| Alabama | R | 12.8% | ~280k | 71% support expansion |
| Mississippi | R | 14.9% | ~210k | 74% support expansion |
| Tennessee | R | 9.1% | ~150k | 68% support expansion |
| South Carolina | R | 11.8% | ~180k | 66% support expansion |
| Kansas | D Gov | 10.4% | ~120k | 72% support expansion |
| Wisconsin | D Gov | 7.2% | ~90k | 73% support expansion |
| Wyoming | R | 12.1% | ~45k | 59% support expansion |
Why Non-Expansion Persists Against Public Majority
GOP Supermajority States
In states like Mississippi, Alabama, and Tennessee, Republican supermajorities in the legislature can block expansion even when governors would sign it. The ideological position — "expanding a failed government program" — is a litmus test issue in Republican primaries. Any Republican who supports expansion risks a primary challenge funded by national conservative infrastructure.
When Voters Decide Directly
Idaho (2018), Utah (2018), Oklahoma (2020), Missouri (2020), and South Dakota (2022) all expanded Medicaid via ballot measure after legislatures refused. Each vote passed. Kansas and Wisconsin, where Democratic governors want expansion, are blocked by Republican legislatures. The ballot measure route requires organized campaigns and is not available in all non-expansion states.
Net Favorability at +19
The ACA's overall favorability is now +19 (58% favorable, 39% unfavorable) — its highest-ever net positive rating. Support for keeping the ACA is at 62% even among voters who want modifications. The 2017 repeal failure has made "repeal and replace" a politically toxic frame; current Republican proposals focus on "reform" language and targeted rollbacks rather than full repeal.
Healthcare as a 2026 Voting Issue
Healthcare: #2 Voting Issue, Behind Only Economy
Healthcare ranks as the second most important voting issue in 2026 polling at 67%, behind the economy (78%). The specific concerns have shifted since 2020: prescription drug costs (89% concerned), insurance coverage affordability (82%), and Medicaid/Social Security/Medicare (76%) are the top sub-issues. The drug pricing provisions of the IRA — allowing Medicare to negotiate prices — have helped Democrats on this front, with 89% of Americans supporting that specific policy.
In competitive Senate and House races, any candidate advocating for ACA repeal faces a significant polling headwind. Republicans running in competitive districts have largely abandoned repeal rhetoric and are instead running on "patient choice" and "competition" messaging that avoids the politically toxic repeal frame.
