When provisions of the Affordable Care Act (ACA) related to the expansion of Medicaid to low-income childless adults took effect in January 2014, 25 states and the District of Columbia had approved laws to broaden their programs' eligibility requirements. Since then, under pressure from various interests groups, including state hospital associations, lawmakers in at least three more states-Iowa, Michigan, and Pennsylvania-expanded their health care safety net programs and thereby gained access to federal dollars that would have otherwise been left on the table.