For most states expanding their Medicaid program in response to the opportunity afforded by the Affordable Care Act, expansion has been fairly straightforward:  they simply let more people into their existing Medicaid programs.

But several states – Arkansas, Iowa, and Michigan – have tried something different:  pursuing fundamental changes in their Medicaid programs.

Among the nearly half of the states still holding out against Medicaid expansion, the “something different” approach appears likely to be more common in the future, and in particular, those that do pursue expansion appear likely to seek to do so through greater use of private health insurers.  Through such an approach, states seek to use new federal Medicaid money to purchase private health insurance for newly qualified Medicaid recipients.

Among the states pursuing, or preparing to pursue, Medicaid expansion through private option coverage or other approaches in 2014 are New Hampshire, Pennsylvania, Tennessee, Virginia, Indiana, Missouri, Montana, and Utah, and others may follow as well.  Many of the programs these and other states propose will require federal waivers to exempt them from current Medicaid law, so the fate of these programs will rest on the Obama administration’s willingness to grant such waivers.

Read more about what these states are considering and the challenges they face in seeking approval for their plans in this Kaiser Health News report.