How GOP Medicaid Overhaul Plans Could Be Blocked by 7 States
The Republican Party has expanded its inclusivity since 2017, reflecting a broader coalition. Additionally, the health care program has also undergone significant changes.
TroibNews 
Republicans are encountering a nationwide backlash regarding Medicaid, particularly in seven conservative-leaning states where voters have opted to expand the program in recent years. The proposed cuts to Medicaid pose significant challenges in these states as Republicans seek savings to fund the White House's proposed tax cuts.
Republican Sen. Mike Rounds of South Dakota, where over 24,000 individuals have enrolled in Medicaid since the 2022 expansion, expressed his opposition to some proposals from his party. One such proposal involves drastically reducing federal funding for the program. “That's not a cost cutting measure — that's a cost transfer,” he said. “And when you've got partnerships with the states, you shouldn't be doing that without having them involved in the discussion.”
Skepticism among Republicans is evident across red and purple areas where voters have expanded Medicaid through ballot initiatives since Congress's last attempt to alter the program in 2017. This includes South Dakota, as well as Idaho, Nebraska, Maine, Oklahoma, Missouri, and Utah. President Donald Trump won all these states, except for Maine, where he still managed to capture an electoral vote against Kamala Harris in the 2nd Congressional District, where nearly a third of residents are on Medicaid.
The conflicting signals from the president to Congress about the extent of potential cuts to the program indicate his awareness of the political risks involved.
As some states consider expanding Medicaid in the future, rollbacks could become an even bigger challenge. There’s currently a campaign in Florida aiming to place an expansion initiative on the 2026 ballot, highlighting the program's continued popularity, even in states that strongly support MAGA policies.
“Cutting Medicaid seems to be popular with some Republican elites and some right wing think tanks that are getting funded by some right wing billionaires, but they're unquestionably not popular with the Republican voters,” Joan Alker, the executive director of the Center for Children and Families at Georgetown University’s McCourt School of Public Policy, told reporters at a briefing on Medicaid this week. “We've seen many polls recently asking voters to rank what they wanted … and cutting Medicaid was literally the last on the list for voters of all stripes.”
In the seven states that approved Medicaid expansion initiatives, coalitions consisting of powerful hospital associations, grassroots advocacy groups, and other unusual allies are reactivating to defend the program. They are organizing town hall meetings, publishing op-eds in local media, engaging in phone campaigns to contact their congressional representatives, and considering reviving tactics used in the 2017 protests against Affordable Care Act repeal attempts.
“We're going back to the old playbook,” said Matt Slonaker, the executive director of the Utah Health Policy Project who led the state's ballot initiative campaign in 2018. “It's always hard to get folks to act, but they seem to be really, really ready to do this right now.”
With mounting pressure to locate hundreds of billions in savings, even lawmakers typically supportive of government spending cuts are wary of the backlash they might face over Medicaid in their states. While they struggle to unite behind Trump’s budget plan, GOP leadership is taking note.
On Wednesday night, House Speaker Mike Johnson retreated from some of the extensive changes the GOP had contemplated, including capping funds for each Medicaid enrollee and rolling back federal support for states that expanded the program. He dismissed the outrage faced by his members at recent town halls as the influence of “paid protesters.”
“All this attention is being paid to Medicaid because that’s the Democrats’ talking point,” Johnson said. “We’re talking about finding efficiencies in every program, but not cutting benefits for people who rightly deserve them.”
Pro-expansion health care groups in the seven red and purple states invested substantial time and resources into ballot initiative campaigns to bypass conservative state legislatures and governors who resisted Medicaid expansion. Now, some state officials are attempting to reverse the expanded coverage that their constituents approved.
This situation has positioned Republicans on Capitol Hill from Medicaid-expansion states as the most vocal and often sole opposition voices against the proposed cuts, given that Democrats are out of power. While some House Republicans in red districts are feeling the pressure, senators have to respond to their entire state's electorate.
“I don't quite think Republicans know the backlash they're in for,” said Brad Woodhouse, a former Democratic National Committee official who now leads the progressive advocacy group Protect Our Care. “And it's going to be a particularly bitter pill in these states that have used ballot initiatives because in those cases, the voters have really spoken about their preference.”
Earlier this week, Republican Sens. Josh Hawley of Missouri and Susan Collins of Maine, both from states that expanded Medicaid via ballot measure, broke from their party to support a Democratic amendment to the Senate budget resolution aimed at blocking tax cuts for the wealthy if Medicaid funding is reduced.
Hawley, representing nearly 326,000 individuals who became eligible for Medicaid under Missouri's 2021 expansion, has stated he wouldn’t support “severe” cuts to Medicaid, especially those that might lead to decreased benefits, deeming it a “red line” for his vote.
The political landscape is particularly complex for representatives of rural states, where Medicaid serves as a crucial support system for financially struggling hospitals, some of which are significant employers within their communities.
In Idaho, for instance, voters approved Medicaid expansion in 2018 with 61 percent support, enabling coverage for about 90,000 additional residents. However, if federal funding for Medicaid is compromised due to the ongoing negotiations in Washington, the state legislature has the authority to intervene and possibly repeal the expansion. Idaho House Minority Leader Ilana Rubel, a Democrat, is among those cautioning that such a move would jeopardize the remaining rural hospitals in the state.
“That's a disaster, not only for the people on Medicaid, but for the people on private insurance,” Rubel said. “Because when you live in these rural areas, you know you can have the best insurance in the world, but if the hospital in your area has gone out of business and you fall off a ladder or have a heart attack, there will be nobody to help you.”
Not every Republican from an expansion state shares concerns about the sweeping reforms advocated by hardliners in their party, however.
Sen. James Lankford of Oklahoma, where over 245,000 people became eligible for coverage after the state voted to expand Medicaid in 2020, echoed Speaker Johnson’s assertion that the final budget would not affect individuals’ health care benefits. He affirmed that he hadn't encountered citizens expressing concerns over potential cuts.
“I have not heard anyone talking about cutting off Medicaid to people,” he said. “It has been dealing with formulas. It's been dealing with fraud.”
Similarly, Utah Sen. John Curtis reported to PMG this week that after discussions with Republican Governor Spencer Cox, he feels optimistic regarding the political ramifications.
He mentioned he is “not near as concerned” about cuts to the safety net program as he is about “the fiscal irresponsibility that we're facing,” maintaining that he’s “in total harmony with our state leaders on this.”
Medicaid enrollment in Utah surged nearly 60 percent after a ballot initiative to expand the program was passed in 2018. Nevertheless, Utah has a “trigger” law that could automatically terminate Medicaid expansion or mandatorily alter the program if federal funding decreases, placing millions at risk of losing coverage.
For Curtis, this is seen as a proactive step rather than a drawback.
“Our state is one of more fiscally responsible states, in my opinion, and they saw this coming,” he said.
Lucas Dupont contributed to this report for TROIB News
Republican Sen. Mike Rounds of South Dakota, where over 24,000 individuals have enrolled in Medicaid since the 2022 expansion, expressed his opposition to some proposals from his party. One such proposal involves drastically reducing federal funding for the program. “That's not a cost cutting measure — that's a cost transfer,” he said. “And when you've got partnerships with the states, you shouldn't be doing that without having them involved in the discussion.”
Skepticism among Republicans is evident across red and purple areas where voters have expanded Medicaid through ballot initiatives since Congress's last attempt to alter the program in 2017. This includes South Dakota, as well as Idaho, Nebraska, Maine, Oklahoma, Missouri, and Utah. President Donald Trump won all these states, except for Maine, where he still managed to capture an electoral vote against Kamala Harris in the 2nd Congressional District, where nearly a third of residents are on Medicaid.
The conflicting signals from the president to Congress about the extent of potential cuts to the program indicate his awareness of the political risks involved.
As some states consider expanding Medicaid in the future, rollbacks could become an even bigger challenge. There’s currently a campaign in Florida aiming to place an expansion initiative on the 2026 ballot, highlighting the program's continued popularity, even in states that strongly support MAGA policies.
“Cutting Medicaid seems to be popular with some Republican elites and some right wing think tanks that are getting funded by some right wing billionaires, but they're unquestionably not popular with the Republican voters,” Joan Alker, the executive director of the Center for Children and Families at Georgetown University’s McCourt School of Public Policy, told reporters at a briefing on Medicaid this week. “We've seen many polls recently asking voters to rank what they wanted … and cutting Medicaid was literally the last on the list for voters of all stripes.”
In the seven states that approved Medicaid expansion initiatives, coalitions consisting of powerful hospital associations, grassroots advocacy groups, and other unusual allies are reactivating to defend the program. They are organizing town hall meetings, publishing op-eds in local media, engaging in phone campaigns to contact their congressional representatives, and considering reviving tactics used in the 2017 protests against Affordable Care Act repeal attempts.
“We're going back to the old playbook,” said Matt Slonaker, the executive director of the Utah Health Policy Project who led the state's ballot initiative campaign in 2018. “It's always hard to get folks to act, but they seem to be really, really ready to do this right now.”
With mounting pressure to locate hundreds of billions in savings, even lawmakers typically supportive of government spending cuts are wary of the backlash they might face over Medicaid in their states. While they struggle to unite behind Trump’s budget plan, GOP leadership is taking note.
On Wednesday night, House Speaker Mike Johnson retreated from some of the extensive changes the GOP had contemplated, including capping funds for each Medicaid enrollee and rolling back federal support for states that expanded the program. He dismissed the outrage faced by his members at recent town halls as the influence of “paid protesters.”
“All this attention is being paid to Medicaid because that’s the Democrats’ talking point,” Johnson said. “We’re talking about finding efficiencies in every program, but not cutting benefits for people who rightly deserve them.”
Pro-expansion health care groups in the seven red and purple states invested substantial time and resources into ballot initiative campaigns to bypass conservative state legislatures and governors who resisted Medicaid expansion. Now, some state officials are attempting to reverse the expanded coverage that their constituents approved.
This situation has positioned Republicans on Capitol Hill from Medicaid-expansion states as the most vocal and often sole opposition voices against the proposed cuts, given that Democrats are out of power. While some House Republicans in red districts are feeling the pressure, senators have to respond to their entire state's electorate.
“I don't quite think Republicans know the backlash they're in for,” said Brad Woodhouse, a former Democratic National Committee official who now leads the progressive advocacy group Protect Our Care. “And it's going to be a particularly bitter pill in these states that have used ballot initiatives because in those cases, the voters have really spoken about their preference.”
Earlier this week, Republican Sens. Josh Hawley of Missouri and Susan Collins of Maine, both from states that expanded Medicaid via ballot measure, broke from their party to support a Democratic amendment to the Senate budget resolution aimed at blocking tax cuts for the wealthy if Medicaid funding is reduced.
Hawley, representing nearly 326,000 individuals who became eligible for Medicaid under Missouri's 2021 expansion, has stated he wouldn’t support “severe” cuts to Medicaid, especially those that might lead to decreased benefits, deeming it a “red line” for his vote.
The political landscape is particularly complex for representatives of rural states, where Medicaid serves as a crucial support system for financially struggling hospitals, some of which are significant employers within their communities.
In Idaho, for instance, voters approved Medicaid expansion in 2018 with 61 percent support, enabling coverage for about 90,000 additional residents. However, if federal funding for Medicaid is compromised due to the ongoing negotiations in Washington, the state legislature has the authority to intervene and possibly repeal the expansion. Idaho House Minority Leader Ilana Rubel, a Democrat, is among those cautioning that such a move would jeopardize the remaining rural hospitals in the state.
“That's a disaster, not only for the people on Medicaid, but for the people on private insurance,” Rubel said. “Because when you live in these rural areas, you know you can have the best insurance in the world, but if the hospital in your area has gone out of business and you fall off a ladder or have a heart attack, there will be nobody to help you.”
Not every Republican from an expansion state shares concerns about the sweeping reforms advocated by hardliners in their party, however.
Sen. James Lankford of Oklahoma, where over 245,000 people became eligible for coverage after the state voted to expand Medicaid in 2020, echoed Speaker Johnson’s assertion that the final budget would not affect individuals’ health care benefits. He affirmed that he hadn't encountered citizens expressing concerns over potential cuts.
“I have not heard anyone talking about cutting off Medicaid to people,” he said. “It has been dealing with formulas. It's been dealing with fraud.”
Similarly, Utah Sen. John Curtis reported to PMG this week that after discussions with Republican Governor Spencer Cox, he feels optimistic regarding the political ramifications.
He mentioned he is “not near as concerned” about cuts to the safety net program as he is about “the fiscal irresponsibility that we're facing,” maintaining that he’s “in total harmony with our state leaders on this.”
Medicaid enrollment in Utah surged nearly 60 percent after a ballot initiative to expand the program was passed in 2018. Nevertheless, Utah has a “trigger” law that could automatically terminate Medicaid expansion or mandatorily alter the program if federal funding decreases, placing millions at risk of losing coverage.
For Curtis, this is seen as a proactive step rather than a drawback.
“Our state is one of more fiscally responsible states, in my opinion, and they saw this coming,” he said.
Lucas Dupont contributed to this report for TROIB News
