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Competing Interests: Conflicts of interest Dr George Hruza served as Chair of the American Academy of Dermatology Association SkinPAC until 2022.

Since 2017, four states have successfully adopted the Medicaid expansion through ballot initiative. We analyze how states could potentially use ballot initiatives to implement these programs. We find there are serious legal and political challenges to expansion by initiative. Only six non-expansion states allow for a ballot initiative to pass and implement the Medicaid expansion. Amongst those states, there are challenges that limit the development, scope, and implementation of an initiative. Whether a state adopts the Medicaid expansion has important implications for health care providers.