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We analyze the 19 states that have not expanded Medicaid. From 2017 to 2026, expansion in these states would increase nominal state costs by less than $60 billion while increasing federal funding by more than $400 billion. Each new state dollar would draw down between $7 and $8 in additional federal dollars. We were not able to estimate offsetting state revenue gains and full state cost savings. Every broad fiscal review conducted in expansion states finds that such offsets are exceeding state cost increases, so expansion is helping overall state budgets.