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Under the Affordable Care Act (ACA), states can expand Medicaid eligibility for nonelderly people up to 138 percent of the federal poverty level (FPL). As of January 2020, 35 states and the District of Columbia had expanded Medicaid, and 15 states had not. Even absent effects of the COVID-19 pandemic and economic crisis, if the 15 remaining states had expanded Medicaid eligibility in 2020, 3.9 million fewer people would have been uninsured, Federal spending on health care would have increased by $30.4 billion, and state spending on Medicaid would have increased by $4.7 billion. This additional state spending would fully or largely be offset by savings in other areas.