When the Supreme Court upheld the Affordable Care Act, the justices also ruled that each state could decide whether or not to accept the ACA’s Medicaid expansion. Some 25 states have chosen not to – primarily those controlled by Republican governors or legislatures who remain vehemently opposed to the Affordable Care Act – claiming that Medicaid expansion would destroy state budgets. Accepting Medicaid expansion would allow thousands of poor residents to quality for health insurance via Medicaid. Not accepting the expansion means that these residents either have to go on the state-based health exchanges or forgo health insurance and pay a penalty to the federal government when filing income taxes (although in truth, many of these people don’t make enough money to have to file income taxes).
To be fair, many of these states are in active debate over Medicaid expansion, with Indiana and Virginia as notable examples. And even without Medicaid expansion, previously uninsured individuals who intend to purchase health insurance on the state exchanges may come to find that they actually were already qualified for Medicaid, even before the Affordable Care Act. They just didn’t know it. In fact, tens of thousands of people required by the Affordable Care Act to get into the insurance market in 2014 will discover they are eligible for Medicaid benefits for which they’ve never applied.
Sadly, there are a millions more who won’t be eligible for Medicaid and will fall into the coverage gap, and the Kaiser Family Foundation has a rough estimate of how many per state.