With Donald Trump now sworn in as the 47th president and Republicans controlling both chambers of Congress, the future of Medicaid is uncertain.  

During his campaign, Trump promised to slash federal spending. And according to a document now circulating on Capitol Hill, House Republicans are considering several Medicaid policy changes that could reduce federal spending by $2.3 trillion, including imposing a per capita cap on federal Medicaid funding, reducing the funding match rate for the Medicaid expansion population, and lowering the federal medical assistance percentage (FMAP) floor from the current 50% level. 

As of January, more than 66.1 million people are enrolled in a managed Medicaid health plan, according to AIS’s Directory of Health Plans. The top 10 Medicaid MCO insurers by membership held about 60.9% of the national market. Centene Corp. alone accounted for 18.6% of the national market and covered Medicaid enrollees in 28 states across the nation. Elevance Health, Inc. and UnitedHealthcare ranked the second and the third largest, holding about 11.0% and 8.8% market share, respectively.

In 26 states, Centene is among the top three insurers by membership within the state’s Medicaid market. Molina Healthcare, Inc., the fourth-largest Medicaid MCO insurer, held 6.0% of the national market and ranked among the top three insurers in eight states. The company has more than 3.9 million Medicaid beneficiaries, accounting for almost 85.5% of its total membership. For more specific market share data, hover over the graphics below.

The Affordable Care Act expanded Medicaid coverage to people with incomes of up to 138% of the federal poverty level. The federal government covers 90% of the cost for ACA expansion enrollees and states pay 10% of the costs. As of 2025, 40 states and Washington, D.C., have adopted Medicaid expansion, as a Supreme Court decision made expansion optional. The FMAP for the non-expansion Medicaid population is based on states’ and U.S. territories’ per capita income and ranges from 50% to 83% for fiscal year 2025, according to KFF. 

The Paragon Health Institute, a right-leaning health care research firm, has proposed reducing the FMAP for Medicaid enrollees to the standard Medicaid match rate by 2034, which could shift a significant amount of Medicaid spending from the federal government to the states and lead to millions of people losing coverage. 

As of March 2024, more than 21 million people — 24% of total Medicaid enrollment — had coverage thanks to the ACA’s expansion provision, according to a KFF analysis. About 4.3 million expansion enrollees reside in 12 states that have “trigger laws” that would end expansion or require other changes if the match rate is below 90%. 

Of the 12 states with the trigger laws, eight voted for Trump as president and four voted for Kamala Harris. In Arkansas, Indiana, Iowa, Montana, New Hampshire, New Mexico and Virginia, more than 30% of Medicaid beneficiaries obtain their coverage through Medicaid expansion. 

This infographic was reprinted from AIS Health’s weekly publication Health Plan Weekly.