Constitutional Amendments Shield Medicaid Expansion
As Republicans in Congress advance proposals to cut federal Medicaid funding by $880 billion over the next decade, many states are scrambling to identify ways to reduce program costs. However, voters in three conservative states—Missouri, Oklahoma, and South Dakota—have created a significant roadblock by enshrining Medicaid expansion in their state constitutions. This unprecedented move has created both a potential budget crisis and a complex political challenge for Republican lawmakers.
These constitutional amendments specifically require Medicaid coverage for all adults under 65 who earn up to 138% of the federal poverty level ($21,597 for an individual in 2025). The protections come at a critical time, as these states are among the 40 plus the District of Columbia that expanded Medicaid eligibility under the 2010 Affordable Care Act, with the federal government currently covering 90% of expansion costs.
Proposed Federal Funding Cuts Create Budget Crisis
The potential slashing of federal support poses an existential threat to state budgets nationwide. Congressional Republicans are considering reducing the 90% federal match rate for expansion populations to the lower rates used for traditional Medicaid recipients—rates that range from just 50% in wealthier states to 77% in poorer ones.
If this proposal becomes law, states would collectively need to find an additional $626 billion over the next decade to maintain coverage for approximately 20 million Americans in the expansion population. The financial burden would be overwhelming for many state budgets already stretched thin.
Nine States Have Automatic Rollback Provisions
Nine states have already prepared for this scenario by implementing laws that would automatically terminate Medicaid expansion if federal funding decreases: Arizona, Arkansas, Illinois, Indiana, Montana, New Hampshire, North Carolina, Utah, and Virginia. Other states are exploring work requirements, educational mandates, or volunteer obligations to trim enrollment numbers and reduce costs.
However, Missouri, Oklahoma, and South Dakota find themselves in a uniquely challenging position because of their constitutional amendments.
Constitutional Protection Creates Unmovable Mandate
“Legislators cannot change that law without going back to voters for a whole other campaign to change the constitution,” explained Kelly Hall, executive director of the Fairness Project, the nonprofit organization that helped place these constitutional amendments on the ballot in all three states.
“Even if the federal government cuts their contribution towards funding Medicaid expansion, those three states do not have the option to reduce eligibility or benefits for the Medicaid expansion population,” Hall told Stateline. “They will have to find those resources.”
Medicaid’s Critical Role in State Finances
The financial implications are staggering because Medicaid represents a massive portion of state budgets. Including federal matching funds, states dedicate an average of nearly one-third of their budgets to Medicaid programs. Moreover, the program constitutes the largest single source of federal funding for states.
Missouri illustrates the magnitude of this challenge. After voters approved a constitutional amendment expanding Medicaid in August 2020, state lawmakers initially refused to fund it. When residents sued, the Missouri Supreme Court ruled in 2021 that the legislature was constitutionally obligated to find the necessary resources—a landmark victory for healthcare advocates.
Potential Budget Shortfalls Reach Billions
For fiscal year 2025, Missouri has allocated $18.2 billion for Medicaid, with the federal government providing $12.7 billion—approximately 70% of the total. If Congress implements the proposed $880 billion reduction in federal Medicaid funding over the next decade, Missouri could face a budget shortfall of around $1.7 billion next year alone, according to research from the Commonwealth Fund.
Limited Options for States with Constitutional Mandates
Timothy McBride, a health policy analyst and co-director at Washington University in St. Louis’s Institute for Public Health, outlined the difficult choices facing Missouri: “raising taxes, cutting enrollment for other Medicaid populations, diminishing reimbursements to providers, getting rid of optional medical services such as dental care, or ceasing payments for equipment like wheelchairs.”
Tax increases remain politically unpalatable in Republican-dominated Missouri, while reducing provider payments could devastate the state’s already fragile healthcare infrastructure.
“We lost 10 hospitals in Missouri in the last few years. And if you start cutting their payment rates, that’s going to just put them at risk,” McBride warned. “The real money is in the disabled and the elderly populations. And so if you really wanted to quote-unquote save money, that’s probably where you’d have to look. But that’s really controversial.”
Political Recalculations Among Republicans
The looming budget crisis has prompted some notable political reversals. U.S. Senator Josh Hawley, a Missouri Republican who previously supported repealing the Affordable Care Act as state attorney general in 2018, now firmly opposes Medicaid cuts.
“I’m not going to vote for Medicaid cuts, benefit cuts. Work requirements are fine. But 21% of the residents in my state receive Medicaid or [the Children’s Health Insurance Program]. That’s a lot of people,” Hawley told reporters in February.
With a closely divided Congress, Republicans may struggle to enact Medicaid cuts if other conservative lawmakers from Missouri, Oklahoma, and South Dakota follow Hawley’s stance.
States Seeking Constitutional Workarounds
In South Dakota, where voters approved Medicaid expansion through a constitutional amendment in 2022, Republican state Representative Will Mortenson described the constitutional approach as “foolish” despite respecting voters’ wishes.
“A constitution is not meant to be a flexible document that you change annually or even every other year,” Mortenson explained. “And so now, as we’re staring down the barrel of the federal government contemplating changes to Medicaid, including for the expansion population, our state is hamstrung in that we cannot effectively respond to those changes.”
Mortenson has sponsored legislation that would ask South Dakota voters to consider a new constitutional amendment conditioning Medicaid expansion on federal funding levels. This measure has already passed both chambers of the state legislature.
Advocates Prepare to Defend Constitutional Protections
Supporters of the original constitutional amendments promise fierce resistance to any changes. Doug Sombke, head of the South Dakota Farmers Union, told Stateline that work requirements or other restrictions would harm working-class individuals, particularly farmworkers who often struggle with low wages and lack employer-provided health insurance.
“There’s just no extra income,” Sombke said. “And, in South Dakota, we’re a right-to-work state, so you can get fired for any reason. As a worker, you really don’t have a lot of choice.”
Constitutional Strategy May Spread to Other States
Hall, from the Fairness Project, believes constitutional amendments represent the most effective strategy for ensuring Medicaid expansion in conservative states. She anticipates voters in other states might pursue similar constitutional protections if their legislatures attempt to roll back expansion.
“I do think that it’s possible that if we see these cuts move forward in D.C., and states are making highly unpopular choices to cut benefits for people, that we will see this issue back at the ballot box,” Hall said. “But for right now, I would say we’re seeing the power of constitutional amendments to protect benefits in action in real time.”
The collision between constitutional mandates and potential federal funding cuts highlights the growing tension between fiscal constraints and healthcare access—a conflict that will likely define healthcare policy debates in the coming years as states grapple with their legal obligations to provide coverage regardless of federal support.
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