The Paragon Health Institute has published a new research report, “Medicaid Expansion’s Growing Improper Enrollment Crisis,” authored by economist Liam Sigaud. The analysis estimates that almost half of the people enrolled through the Affordable Care Act’s Medicaid expansion in 2024 may not have satisfied the program’s eligibility requirements. According to the report, improper enrollment resulted in an estimated $32.9 billion in federal expenditures during 2024, with states shifting a significant portion of the financial burden to federal taxpayers.

The report was released alongside testimony from Paragon President Brian Blase, Ph.D., before the U.S. Senate Budget Committee during a hearing titled “Medicaid: The Reality.”

Blase emphasized that Medicaid funding must be directed toward individuals who legitimately qualify for assistance. He noted that money spent on people who are not eligible reduces the resources available for vulnerable groups, including children, pregnant women, seniors, and individuals with disabilities. According to Paragon’s findings, improper enrollment has become widespread across Medicaid expansion programs in a number of states.

Sigaud’s analysis builds on earlier Paragon research by comparing Census Bureau survey information with state Medicaid enrollment data. The study estimates that approximately 9.2 million of the 20.2 million people enrolled through Medicaid expansion in 2024 may have been ineligible, representing about 46 percent of total expansion enrollment. Even when applying a more cautious methodology that assumes all eligible individuals were enrolled, the research still identifies more than 5 million potentially improper enrollees.

The report attributes part of the problem to the way Medicaid expansion is financed. Under the ACA, the federal government covers at least 90 percent of the cost of expansion beneficiaries, substantially reducing the financial responsibility of individual states. Paragon argues that this arrangement can encourage states to maximize the number of people classified under the expansion category in order to increase federal reimbursement.

Major findings from the report include:

The research also indicates that Medicaid expansion enrollment remained considerably higher than pre-pandemic levels even after states completed eligibility reviews and enrollment in traditional Medicaid moved closer to its pre-pandemic level.

According to the report, the underlying financing model of the ACA may contribute to these enrollment problems. The federal government covers at least 90 percent of expenses for Medicaid expansion beneficiaries, compared with approximately 57 percent for traditional Medicaid populations. Paragon argues that this difference can give states a financial reason to maximize enrollment in the expansion category, including by placing beneficiaries who would otherwise qualify for traditional Medicaid into the more generously funded expansion group.

The report acknowledges that Congress and the Trump Administration have already introduced several measures intended to address these concerns. These include requiring eligibility reviews for expansion beneficiaries at more frequent intervals and establishing penalties associated with excessive eligibility errors.

Paragon argues that additional steps are needed to strengthen the program’s integrity. Its recommendations include improving eligibility verification procedures, increasing oversight of state enrollment practices, and eventually restructuring federal matching arrangements so that states no longer have financial incentives to prioritize able-bodied, working-age adults covered under Medicaid expansion over beneficiaries traditionally eligible for Medicaid.

The complete report, “Medicaid Expansion’s Growing Improper Enrollment Crisis,” is available through the Paragon Health Institute.

The report’s conclusions were also discussed in a Wall Street Journal opinion article by Liam Sigaud and Brian Blase, titled “How California Cheats ObamaCare’s Medicaid Expansion,” published on August 2, 2026. The article examines how Medicaid’s funding structure can encourage states to increase expansion enrollment while transferring a larger share of the resulting costs to federal taxpayers. Fox Business also reported on the research in an exclusive news report.

A recent HelloNation article examines the role Medicaid planning plays in helping individuals and families prepare for the financial challenges associated with long-term care. The piece explores how Medicaid regulations influence healthcare funding, asset preservation, and financial decision-making when ongoing medical support becomes necessary.

The article draws on the expertise of Andrew R. Randisi, Esq., MBA, of Weinstein & Randisi in Rochester, New York. It notes that many families begin exploring Medicaid planning only after a serious health event creates an immediate need for nursing home care or extended medical assistance. Once care becomes necessary, concerns regarding personal savings, property ownership, and future financial security often emerge.

According to the article, Medicaid planning is frequently misunderstood, particularly during periods of stress. Some people mistakenly believe the process is intended to conceal assets or bypass legal responsibilities. In reality, Medicaid planning focuses on identifying legitimate legal and financial strategies that can help families navigate the high costs of care while remaining compliant with applicable regulations.

The article explains that Medicaid eligibility and planning options vary considerably based on factors such as income, assets, health status, marital circumstances, and timing. As a result, strategies that may benefit one individual or family may not be suitable for another. Understanding these distinctions can help families make informed decisions before their available options become more limited.

Asset preservation is another key subject discussed in the article. Many families assume Medicaid planning can fully protect all assets while ensuring immediate qualification for benefits. However, the article clarifies that such expectations are often unrealistic. Certain legal approaches may help safeguard some resources or provide financial protections for a spouse who remains at home, but other assets may still need to be used to cover long-term care expenses.

The article further highlights the financial impact that nursing home services, assisted living arrangements, and in-home care can have on retirement savings. Families that postpone planning discussions may find themselves making critical decisions during emotionally difficult circumstances or medical emergencies. Beginning the conversation earlier often provides greater flexibility and a clearer understanding of available planning opportunities.

In addition, the article outlines several Medicaid planning tools, including trusts, exempt asset provisions, income-planning techniques, and asset transfer strategies. Each option is subject to specific legal requirements and timing restrictions. Medicaid's look-back rules review certain financial transactions completed before an application is filed, and non-compliant transfers can result in penalties or delays in eligibility.

For married couples, Medicaid planning often involves balancing asset protection with the financial needs of a spouse who continues living independently. The article explains that Medicaid regulations may provide limited protections for a community spouse, potentially allowing retention of certain savings, income, or a primary residence. Nevertheless, these safeguards have limitations and require careful evaluation within the context of the family's overall financial picture.

Estate planning is also an important component of the discussion. The article notes that state Medicaid recovery programs may seek reimbursement from certain assets after a recipient's death. Consequently, many families choose to coordinate Medicaid planning with estate planning rather than addressing them separately. Taking a comprehensive approach can help clarify how present-day financial decisions may influence future outcomes.

The article concludes by emphasizing that Medicaid planning cannot undo every financial choice made in the past. Families who wait until long-term care is immediately required may discover that fewer planning opportunities remain available. Proactive planning generally provides more time to assess available strategies and determine what protections may realistically be achieved.