Republican lawmakers in three states want voters to change or abandon Medicaid expansion

In three conservative states – Missouri, Oklahoma and South Dakota – residents have voted in recent years to amend state constitutions to expand Medicaid under the Affordable Care Act.

Now Republican lawmakers in all three states want voters to change or reject those amendments in the upcoming election, setting the stage for lawmakers to stop the expansion.

Constitutional amendments approved by Missouri and Oklahoma voters in 2020 and South Dakota voters in 2022 require state Medicaid programs to cover all adults under age 65 who earn at least 138% of the federal poverty level, or $22,024. Forty-one states and the District of Columbia have expanded Medicaid eligibility.

Expansion supporters in Missouri, Oklahoma and South Dakota have asked voters to amend their state constitutions to circumvent opposition from GOP-led legislatures. Despite the success of these citizen initiatives, Republicans in all three states – the only three with constitutional amendments to expand Medicaid – maintained their reluctance to expand, and were emboldened by President Donald Trump’s return to the White House.

Medicaid is funded jointly by the federal government and the states. Last summer, Trump signed a sweeping tax and spending order that is estimated to cut federal Medicaid spending by about $886.8 billion over the next decade, largely because fresh work requirements push people out of work. according to Congressional Budget Office estimates.

Under the ACA, better known as Obamacare, the federal government covers 90% of the costs of supporting a growing population. But expansion opponents have long questioned the federal government’s long-term commitment to the game.

Recent changes at the federal level have only fueled those concerns, said Curtis Shelton, policy director at the Oklahoma Public Affairs Council, a right-leaning think tank.

“Now that people have seen how expensive this program will be, I think it’s fair to ask voters if they want to reconsider early voting,” Shelton said. “We don’t really have the sustainable ability to fund this. So it’s either going to come from massive tax increases or cutting benefits for the traditional Medicaid population.”

Amber England, founder and CEO of STRATEGY 77, an Oklahoma-based public affairs firm that has pushed for expansion in the country, said any measure that undermines the constitutional integrity of expansion is tantamount to repeal, “because they get it in their hands the second legislature, they will reduce it to zero.”

“Most importantly, it actually takes power away from voters because Oklahoma voters have already decided on this issue,” England said.

In Oklahoma, voters may be asked to consider two Medicaid expansion proposals in the coming months. You could remove Medicaid expansion from the state constitution and put it in place in state statuteallowing lawmakers to change it. Second change the amendment so that Oklahoma can end its expansion if the federal score falls below 90%.

Oklahoma lawmakers are debating whether to include one ballot in the special election in August or include both on the regular ballot in November.

In South Dakota, voters will also be asked to do so change the Medicaid amendment so that it no longer applies if federal funding falls below 90%. This measure was approved until the November vote.

The situation in Missouri is more complicated.

After Missourians voted for a constitutional amendment, state lawmakers rejected to fund Medicaid expansion, prompting a lawsuit from residents. In 2021, the state Supreme Court ruled that the legislature had to pay for the extension.

In its ruling, the state Supreme Court cited a portion of the amendment prohibiting the imposition of “greater or additional burdens or restrictions” on people who qualify for Medicaid under the expansion.

The measure that Missouri Republicans want to put before voters would add work requirements for people covered by the Medicaid expansion. The fresh labor rules will be identical to those included in the federal law Trump signed last summer.

Missouri Republican Darin Chappell, sponsor Missouri measurehe said Missouri Independent. that he wants to make sure Missouri maintains its Medicaid work requirements even if the federal government one day reverses.

However, Chappell’s proposal would also remove the language “greater or additional burdens or limitations” that the state Supreme Court cited in its 2021 ruling. It would also remove a provision requiring Missouri to “take any action necessary to maximize the federal financial share in financing” Medicaid expansion.

Taken together, Democrats say the changes will make it easier for Missouri lawmakers to block expansion funding.

Missouri Democratic Republican Ashley Aune, the House minority leader, told reporters that preventing funding for Medicaid expansion is “the only reason Republicans want to put this measure before Missouri voters,” according to the Missouri Independent.

The Missouri House in February approved the measure on a party-line vote in November, but the Senate is still considering it.

Kelly Hall, executive director of the Fairness Project, a nonprofit that helped put the constitutional amendments on the ballot in all three states, said the fact that lawmakers must go to voters to make changes “is a testament to the strength of the original strategy.”

“But it is still absolutely disgusting that lawmakers are trying to take away people’s health care and go against the will of their own voters by trying to return to voting rules,” Hall said.

Idaho, Maine, Nebraska and Utah also expanded Medicaid through ballot initiatives, although none of those states amended their constitutions and voters won’t see Medicaid on the ballot this fall.

However, Utah is one of the nine states of expansion (The others are Arizona, Arkansas, Illinois, Indiana, Montana, New Hampshire, North Carolina and Virginia) with provisions that would automatically roll back Medicaid expansion if the federal contribution falls below 90%.

Stateline reporter Shalina Chatlani can be reached at: schatlani@stateline.org.