Abstract Background Federal changes in Medicaid policy are the subject of significant national attention and debate. In contrast, state level Medicaid policies are more of a black box: difficult to keep track of and much less salient. These disparate attention and information contexts obscure the important ways that federal and state Medicaid policy compare. Methods We present original policy data that identifies nearly 4,000 proposed state Medicaid bills from 2018-2022 Results We show that the recent and ongoing federal emphases on reducing Medicaid expenditures are misaligned with state policy efforts. Moreover, though current federal policy changes have openly eschewed a focus on equity, we find that state level policies with an explicit emphasis on equity fare equally well (in terms of passage) as those without such an emphasis. Far from cutting their programs, states have consistently expanded access to Medicaid. And when state Medicaid policy focuses on equity, it remains politically feasible. Conclusion Altogether, we find that many state Medicaid programs innovate and expand in attempts to offer vital services to their constituents. In an era of federal policy retrenchment, this raises concerns about states’ capacity to continue such efforts.
Beals et al. (2026) studied this question.