The collapse of the congressional Republican attempts to replace the Affordable Care Act have ensured that the broad expansion of Medicaid to low-income able-bodied adults is unlikely to be repealed. But nor have many additional states since leapt to expand their programs.

As currently structured, states have little freedom to target the enhanced matching funds associated with the expansion of Medicaid at the beneficiaries in greatest need of assistance. This has inflated the cost of the program’s expansion, eroded incentives for work, and deterred non-expansion states from extending funds to address the most acute unmet needs.