Opinion: Alabama should celebrate the ACA’s 16th birthday by expanding Medicaid

The Affordable Care Act turns 16 on March 23. It should be a moment to celebrate one of the most important expansions of health coverage in modern history. Instead, recent federal cuts have left thousands of Alabama families facing rising premiums and growing uncertainty about how to afford basic care.

The so-called One Big Beautiful Bill Act (OBBBA) and other federal policy changes severely undermined the Affordable Care Act (ACA). Those cuts are hitting Alabama especially hard because our state is one of only 10 yet to expand Medicaid to cover adults with low incomes. It’s time for Alabama to take that step.

Recent federal cuts have eroded our state’s progress on health coverage. Alabama reached record enrollment in HealthCare.gov plans in 2025, when more than 90% of enrollees used enhanced ACA premium tax credits to reduce costs. But the expiration of those credits in December pushed thousands of Alabamians off their plans and left many more underinsured.

Early 2026 enrollment data shows that around 20,000 fewer Alabamians selected Marketplace plans this year. We will not know the full number of people who have lost coverage until more data is released later this year. But we know that amid a growing affordability crisis, more families across our state are being priced out of coverage. Health insurance premiums are doubling or tripling for many.

At the same time, Alabama’s health care system is on life support. Rural hospitals continue to close or cut services. Emergency departments are stretched thin. Many communities have no local access to maternity care or mental health treatment. And cuts to federal Medicaid funding deepen these challenges.

Alabama already has more than a dozen rural hospitals at risk of closure, and many facilities are operating in the red. Without action, more closures are likely, and the consequences for rural communities will be severe.

Congress recently passed the Rural Health Transformation Program (RHTP) to help states stabilize rural hospitals. But it is no substitute for Medicaid expansion. One‑time federal dollars cannot sustain hospitals year after year, especially when uncompensated care continues to rise and hundreds of thousands of people remain uninsured. RHTP funding would work far more effectively alongside Medicaid expansion, which would provide an ongoing revenue source for hospitals.

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Medicaid expansion is the most powerful tool Alabama has to stabilize its health care system and protect workers. About 154,800 Alabamians would gain coverage under Medicaid expansion, even after accounting for new federal work reporting requirements. These are workers who keep our state running. They are people in retail, food service, child care, construction, home care and other essential jobs who earn too much to qualify for Medicaid but far too little to afford private insurance.

Expanding Medicaid is more than a financial decision. It is a commitment to the health and stability of Alabama’s people and communities. When parents can see a doctor, children thrive. When workers can afford prescriptions, they stay healthy enough to stay on the job. And when rural hospitals remain open, entire communities survive. Medicaid expansion strengthens families, supports local economies and gives people the chance to live healthier, more secure lives.

The benefits of expansion far outweigh the challenges. New OBBBA provisions limit how Medicaid expansion states can collect provider taxes, which would require Alabama to rethink how it funds its share of Medicaid. But by not expanding Medicaid, Alabama will lose $181.6 million in 2026 by covering health care spending that otherwise could be paid for by the federal government, a Families USA analysis estimates. Even after accounting for $110 million in new costs projected under the OBBBA, Medicaid expansion still would generate $71 million in net savings for Alabama.

Protecting health care access must be a priority for our state. Gov. Kay Ivey recently pledged $40 million to help Jackson Hospital in Montgomery remain open. Medicaid expansion is a cost-effective investment that would strengthen every hospital in the state and help hard-working Alabamians stay healthy. Alabama can and should make that investment.

The path forward is clear. Alabama still can expand Medicaid. Alabama still can increase access to affordable health care. And Alabama still can protect its hospitals, workforce and economy.

The opportunity remains, and the need has never been more urgent. It’s time for Alabama to save lives, create jobs and expand Medicaid.

Debbie Smith is the Cover Alabama campaign director for Alabama Arise, a statewide, member-led nonprofit organization advancing public policies to improve the lives of Alabamians who are marginalized by poverty. Arise’s membership includes faith-based, nonprofit and civic groups, grassroots leaders and individuals from across Alabama. Email: debbie@alarise.org.