As of February 2014, 25 states and the District of Columbia have expanded Medicaid to adults up to 133 percent of the federal poverty level (FPL), while 25 states are still considering expansion or have not chosen to expand. Of those implementing or pursuing expansions, four states — Arkansas, Iowa, Pennsylvania and Michigan — have bypassed the Affordable Care Act’s (ACA) expansion pathway and are pursuing alternative models.

This brief from the Center for Health Care Strategies (CHCS), made possible through support from the Robert Wood Johnson Foundation, outlines key program design features of alternative Medicaid expansion models. The brief also describes the premium assistance models that Arkansas, Iowa, and Pennsylvania developed to use Medicaid funds to purchase private health insurance, as well as Michigan’s proposal to expand Medicaid using a health savings account approach. Key themes emerging from these non-traditional proposals include: (1) a preference for solutions relying more on the private insurance market than on traditional Medicaid; and (2) an emphasis on higher enrollee cost-sharing, personal responsibility, and healthy behaviors.

States that have not yet expanded Medicaid can look to these non-traditional expansion proposals for ideas on expanding coverage to previously uninsured individuals. CHCS developed this brief in response to interest from Medicaid Leadership Institute fellows.