If Congressional Republicans experience some of the deep Medicaid cuts they are considering, the three states will remain particularly tightly tied up.
South Dakota, Missouri and Oklahoma have state constitutions that require them to participate in Medicaid expansion, part of Obamacare, which has expanded its poor health programs to millions of adults.
If Republicans choose to cut Medicaid expansion and make the expected budget cuts, the other 37 states (and DC) participating in the expansion could be stopped covering working-class adults. Nine states have laws that explicitly require the spread of Medicaid to be stopped.
But South Dakota, Missouri and Oklahoma cannot. They need to amend the Constitution, a long process that could possibly take years by cutting back on other services or increasing taxes.
The constitutional amendment was put on state vote by progressive activists who wanted to entrench the Medicaid program in places hostile to that part of the Affordable Care Act. I had two ideas. It's about health insurance for more people and connecting more states and their Republican lawmakers to Medicaid.
The voting initiative has been passed with a wide margin, and these states now rest on Congressional debate over Medicaid. Even conservative senators like Josh Hawley of Missouri are opposed to reducing program funding. Republican senators from three states with constitutional amendments could become an unlikely part of the firewall against a massive cut to Medicaid.
“Expanding Medicaid anywhere protects it wherever we see it,” says Kelly Hall, executive director of Fairness Project, the nonprofit that organized the constitutional reform campaign. She said her group hopes the expansion will expand support for the program in Washington.
The exact details of the cuts are still unknown, but Congressional Republicans hope to enact a detailed plan by the end of September. The budget resolution passed by the House last month called for a cut of at least $880 billion from the committee overseeing Medicaid over a decade. If all the cuts come from Medicaid, that amount represents an 11% reduction in federal Medicaid spending, and millions are likely to lose compensation. The Senate passed its own budget on Saturday, which included the House number, but wasn't very clear about the scope of its preferred spending cuts.
Lawmakers and policy analysts who support Cut have argued that the state will no longer pay a fair share of Medicaid bills. In recent years, the federal share of spending on programs has increased from about 60% to over 70% overall. The federal government pays 90% of the cost of working-age adults registering through expansion, an Obamacare architect intended to ease the burden of expansion from the state's budget.
States with constitutional amendments will have particularly high economic interests, as states will become liable for what was once paid by the federal government. In Missouri, Medicaid funding accounts for about 35% of the state's total budget. If the federal government retreats, states will likely need to raise or cut other parts of their budget, such as education and transportation.
When Republicans attempted a massive Medicaid change in 2017 as part of the push to abolish Obamacare, some Republican governors lobbyed senators to protect the program, while some voted against the bill. Since then, seven more Republican-led states have expanded Medicaid through voting measurements, expanding coverage to 950,000 people.
Even after it was voted, the expansion of Medicaid still opposed opposition from elected officials charged with program setup. Former Maine Governor Paul Lepage went the farthest, claiming he would go to prison instead of expanding Medicaid. (The expansion was implemented after he was replaced by Democrats.)
That resistance has led to progressive activists who organized and funded voting initiative campaigns in search of ways to make Medicaid's expansion more ironclad. In 2020, they came up with the idea of pursuing a voter referendum to ensrine participation in the state's constitutional program. They were successful in Missouri and Oklahoma in 2020, followed by South Dakota in 2022.
These voting initiatives took more work and required more signatures to reach the vote. Activists have determined that the extra hurdles to keep Medicaid entrenched in areas of the country that were hostile to the program were worth it.
Republican politics has also changed since 2017, from austerity from tea parties to working class populism. Hospitals also rely on Medicaid as Medicaid expands, making it more effective to discuss this point with government officials.
“The system is much better in place than it was eight years ago,” said Brendan Buck, an aide to Speaker Paul Ryan during the 2017 Obamacare absentee and a telecom company partner who now works for clients in the healthcare industry. “These are our states. These are our voters, and I think we'll hear loudly and clearly whether this is a real threat.”
When he was Missouri's attorney general, Holy led two lawsuits attempting to overturn the Affordable Care Act. But again in February and this week, he voted with Democrats on budget revisions to protect Medicaid. These efforts were primarily ritualistic. But Republicans may need to vote later this year to advance a massive tax cut and spending cut package.
“Our voters voted for it — my constituents — at a decisive margin,” Holly said in a recent interview about the expansion of Medicaid, saying a fifth of the state has health insurance through the program.
Holy said he would resist voting to add job requirements to the program, but he said he “is not going to vote to cut benefits.”
South Dakota Sen. Mike Round is also opposed to cut federal funds for the expansion of Medicaid, as the state is subject to financial burdens. “That's not a measure of cost savings. It's a cost transfer,” he told Politico in February.
Even many blue states that expanded Congress would likely stop Medicaid compensation for poor adults if cuts were made. Twelve states, including Illinois and Virginia, have passed laws that automatically withdraw expansions if federal funds fall.
States with constitutional amendments are already beginning to prepare for the potential for major budget holes. For example, in Oklahoma, federal Medicaid funding accounts for almost 30% of the statewide budget.
A conservative Oklahoma think tank suggests that states will cut back on other parts of Medicaid to make up for gaps rather than immerse themselves in funding for services such as roads and schools.
But cutting Medicaid services alone would not be enough to offset lost federal funds. There are only a handful of ways states are allowed to cut programs, such as ending prescription drug coverage or no longer providing insurance for postpartum women.
In South Dakota, Congress passed the law in February, changing the constitution to leave the program if federal funds fall.
The new law won't immediately separate South Dakota from the expansion of Medicaid, but it gives Congress the flexibility to do so. To change the constitution, voters should also consider new voting initiatives scheduled for the next 2026 state election.
“I'm worried it won't be soon, but the next election is when it's the case,” said Tony Benyzen, who introduced the bill in January as a member of the state legislature. “There's no other way.”
Catie Edmondson contributed the report.
