Why are Republicans targeting these specific states?

These three states are uniquely vulnerable because voters approved Medicaid expansion through constitutional amendments, bypassing GOP-controlled legislatures. Republicans are now seeking to undo or modify those amendments via new ballot measures.

What changes are Republican lawmakers proposing to Medicaid expansion?

Proposals vary by state but include adding work requirements to the expansion population in Missouri, while Oklahoma and South Dakota lawmakers are pursuing similar ballot measures framed as giving voters a second look at prior decisions.

GOP Lawmakers Push to Reverse Medicaid Expansion in 3 States

Q: Which states are facing efforts to reverse Medicaid expansion?

Missouri, Oklahoma, and South Dakota — the only three states where voters embedded Medicaid expansion directly into their state constitutions — are facing Republican-led efforts to put the issue back on the ballot.

Republican lawmakers in Missouri, Oklahoma, and South Dakota are pushing to put Medicaid expansion back on the ballot, a move that could strip health coverage from hundreds of thousands of low-income adults who gained it through voter-approved constitutional amendments.

The effort targets the only three states where voters embedded Medicaid expansion directly into their state constitutions. Missouri and Oklahoma approved those amendments in 2020. South Dakota followed in 2022. All three required their state Medicaid programs to cover adults under 65 earning at or below 138% of the federal poverty level, which works out to $22,024 a year. Supporters pushed the ballot route specifically because GOP-controlled legislatures had blocked expansion through normal channels.

That strategy worked. It’s also what Republicans are now trying to undo.

Missouri state Rep. Darin Chappell is backing a ballot measure that would add work requirements to the state’s expansion population. House Majority Leader Alex Riley, also a Republican, has been part of those conversations in the Missouri House. In Oklahoma and South Dakota, Republican lawmakers are pursuing similar paths, each framed as giving voters a second look at what they approved several years ago.

The political opening comes from Washington. Last summer, President Donald Trump signed a broad tax and spending measure that the Michigan Advance reports is projected to cut federal Medicaid spending by an estimated $886.8 billion over the next decade, driven largely by new federal work requirements that the Congressional Budget Office projects will push large numbers of people off the program. The federal government currently covers 90% of costs for the expansion population under the Affordable Care Act. That federal match is what expansion critics have long said they don’t trust.

Curtis Shelton, policy director for the Oklahoma Council of Public Affairs, a right-leaning think tank, said the recent federal changes have made the financial picture harder to ignore.

“Now that people have seen just how costly the program is going to be, I think it’s fair to ask voters whether or not they want to reconsider that initial vote,” Shelton said. “We don’t really have sustainable options to fund that. So it’s either going to come from massive tax increases or from benefits being cut for your traditional Medicaid population.”

That framing matters in Michigan, too. Michigan expanded Medicaid in 2013 under what became known as the Healthy Michigan Plan, and the state now covers roughly 2.7 million residents through Medicaid. Michigan didn’t go the constitutional amendment route, so the legislature here has more flexibility to act on its own if federal funding erodes. That flexibility cuts both ways. A Lansing dominated by Republicans facing budget pressure from federal cuts could revisit eligibility rules without needing a vote of the people.

The opposition to what’s happening in Missouri, Oklahoma, and South Dakota is direct. Amber England, founder and CEO of STRATEGY 77, an Oklahoma-based public affairs firm that led the push for expansion there, said any measure that chips away at the constitutional structure of expansion amounts to repealing it outright. England didn’t mince words about what’s at stake for the people covered.

Forty-one states plus Washington, D.C. have expanded Medicaid under the ACA. The three states at the center of this fight are the only ones where voters made expansion a constitutional right, which is precisely why the push to undo it is playing out through ballot measures rather than straight legislative votes. You can’t legislate around a constitutional amendment. So Republicans in these states are trying to get voters to rescind what voters previously approved.

The Congressional Budget Office’s analysis of the federal spending bill Trump signed puts the weight of those cuts on the expansion population specifically. Work requirements, new eligibility checks, and reduced federal matching rates are all part of how the federal government gets to that $886.8 billion figure over ten years, and state budgets will feel the pressure long before that decade is up.

For anyone watching this from Michigan, the practical question is what happens to state Medicaid budgets when the federal share shrinks and legislatures have to decide who gets cut first. The three-state fight over constitutional amendments is the sharpest version of that question right now, but it’s the same math every Medicaid expansion state will face as federal funding tightens over the next several years.