Health insurance for millions could vanish as states put Medicaid expansion on chopping block

Republican lawmakers in several states have Medicaid expansion in their crosshairs, energized by President Donald Trump's return to the White House and a GOP-controlled Congress set on reducing spending on the public health insurance program for low-income people.

As the feds consider cuts to Medicaid, some states are already moving to end or shrink their expanded Medicaid programs.

Legislators in Idaho have introduced a bill that would repeal voter-approved expansion, while Republicans in Montana are considering allowing their expanded program to expire. Some South Dakota lawmakers want to ask voters to let the state end expansion if federal aid declines. Nine other states already have trigger laws that will end their expansion programs if Congress cuts federal funding.

Meanwhile, discussions have stalled in non-expansion states such as Alabama, as lawmakers wait to see what the Trump administration will do.

Many conservatives argue that Medicaid expansion has created a heavy financial burden for states and that reliance on so much federal funding is risky. They argue that expansion shifts resources away from more vulnerable groups, such as children and the disabled, to low-income adults who could potentially get jobs.

In South Dakota, where voters approved Medicaid expansion in 2022 by a constitutional amendment, Republican state Sen. Casey Crabtree wants to bring expansion before voters again with a trigger measure. He told Stateline via text that his proposed amendment to the state constitution "empowers voters to maintain financial accountability, ensuring that if federal funding drops below the agreed 90%, the legislature can responsibly assess the state's financial capacity and the impact on taxpayers while still honoring the will of the people."

But even some Republicans are uneasy about what repealing expansion would mean for their constituents.

"Quite honestly, I have received hundreds of emails from constituents that have said, 'please do not repeal.' I have received zero asking me to repeal, which I think is very telling," said Idaho state Rep. Lori McCann, a Republican who represents a swing district in the northern part of the state.

McCann said she's interested in reining in Medicaid costs, but skeptical about a full expansion repeal. More than 89,000 Idahoans could lose their coverage if the state repeals its expansion, according to the latest numbers from the Idaho Department of Health and Welfare. McCann said she learned this month that only a fraction of those would qualify to buy discounted insurance on the state exchange.

"For the rest, what's going to happen to them? They will utilize the emergency rooms again, and we'll be back to the same problems we had prior to the Medicaid expansion."

Before President Barack Obama signed the Affordable Care Act into law in 2010, traditional Medicaid insurance was mainly available to children and their caregivers, people with disabilities and pregnant women. But under the ACA's Medicaid expansion program, states can extend coverage to adults making up to 138% of the federal poverty level — about $21,000 a year for a single person — and the federal government will cover 90% of the costs for those newly eligible enrollees. States kick in the rest.

All but 10 states, most of them controlled by Republicans, have taken the deal. Nationwide, more than 21 million people with low incomes get their health insurance because of expanded Medicaid eligibility.

But the Trump administration and a Republican-controlled Congress are seriously considering options for shrinking Medicaid as they look for ways to pay for extending tax cuts enacted during Trump's first term in office. Proposals include reducing the federal 90% funding match, which could shift a greater chunk of Medicaid spending onto states, and greenlighting extra hurdles such as requiring enrollees to work in order to qualify for coverage.

The swirl of uncertainty at the federal level is supercharging efforts by Republican state lawmakers who have long opposed the program, despite its popularity.

In a public address last month, Arkansas Gov. Sarah Huckabee Sanders, a Republican, announced the state would ask the federal government for permission to institute work requirements for adults to qualify for coverage.

"If you want to receive free health care — paid for by your fellow taxpayer — able-bodied, working-age adults have to work, go to school, volunteer or be home to take care of their kids," she said.

Sanders argued coverage without such requirements discourages people from working and being self-sufficient.

But advocates and experts point to a wide body of research that links Medicaid expansion to lower uninsured rates, better health care outcomes and economic benefits for states, hospitals and other providers.

Without expansion, they say, many of the working poor who don't have employer-sponsored insurance exist in a coverage gap: They don't earn enough to afford private insurance, and yet they earn too much to qualify for traditional Medicaid. Expansion bridges that gap.

And, advocates argue, yanking health insurance from tens of thousands of people in a state would have far-reaching consequences for families, hospitals and state finances.

"It would be absolutely disastrous for everybody at all levels of the state," said Idaho Democratic state Rep. Ilana Rubel, the House minority leader, who is on the committee considering bills that could repeal the state's Medicaid expansion.

"We would go right back to people being unable to seek preventative care until it's too late, back to loss of life, loss of health and financial catastrophe."

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A coordinated national effort

Many of the attempts to repeal Medicaid expansion in states such as Idaho and Montana are coordinated by national conservative-backed groups, said Joan Alker, executive director of Georgetown University's Center for Children and Families.

"It's important to understand this is part of a well-orchestrated and financed effort to undermine Medicaid generally, especially for adults," said Alker, who is also a research professor at Georgetown's McCourt School of Public Policy, where her work focuses on Medicaid and the Children's Health Insurance Program.

Conservative-backed think tanks, including the Foundation for Government Accountability and the Paragon Health Institute, have testified before several state legislatures against Medicaid expansion and have worked to thwart state ballot initiatives.

In Montana, where Medicaid expansion is set to expire this year unless the legislature and governor opt to renew it, representatives from the foundation and the institute urged state lawmakers to scrap Medicaid expansion. Montana Republican state Rep. Jane Gillette, a dentist, appeared in a video produced by the foundation advocating for the state to allow its expansion to expire.

Neither organization responded to interview requests.

In Idaho last year, state Rep. Jordan Redman, a Republican, ceded most of his time introducing his Medicaid bill to a representative from the Foundation for Government Accountability. That bill later failed to advance out of committee after intense public pushback.

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'Repeal in sheep's clothing'

This month, Redman revived his Medicaid bill. It would repeal Medicaid expansion next year if the federal government does not maintain the 90% match and the state does not receive federal permission to enact work requirements and a host of other new restrictions, including a 50,000 cap on expansion enrollment — just over half of its current enrollment — and a three-year limit on receiving benefits.

"This safeguard approach will strengthen Idaho's Medicaid program while maintaining flexibility," Redman told the Idaho House Health & Welfare Committee earlier this month. "If the federal government or state agencies fail to meet the program's safeguards, this legislation ensures those Medicaid dollars will be redirected to serve the truly needy." Redman did not respond to an interview request from Stateline.

Rubel, the Democratic leader, described Redman's bill as "Medicaid repeal in sheep's clothing."

"It's a type of trigger law with incredibly unlikely-to-be-met conditions," she said. "Basically, they're saying unless you can fly a unicorn to the moon and back, Medicaid expansion will be repealed."

Idaho voters approved Medicaid expansion by ballot measure in 2018, with nearly 61% in favor. The law took effect in 2020.

Conservative lawmakers in Idaho have tried without success to repeal Medicaid expansion ever since, including introducing another repeal bill last month. But this could be conservatives' year. Before the session, Idaho's Republican House speaker expanded the committee from 13 seats to 15. It's a move that some state Democrats say was an effort to ram through Medicaid expansion repeal. At least eight committee members have pledged support for the Idaho Republican Party's platform, which calls for repeal of Medicaid expansion.

Medicaid is popular nationally, in expansion and non-expansion states. Three-fourths of Americans have a favorable view of Medicaid, according to a January 2025 health tracking poll from KFF, a health research organization. It's a preference that crosses political boundaries: 63% of Republicans, 81% of independents and 87% of Democrats view it favorably.

Polling in Idaho in 2023 found 75% of voters — including 69% of Republican voters — held a favorable view of Medicaid.

"Citizens should not have to work this hard to get something passed that they want and need so desperately, and then keep imploring legislators not to take it away again," said Rubel.

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Trigger laws

If Congress reduces the 90% federal match rate for Medicaid expansion, more than 3 million adults could immediately lose their health coverage.

That's because nine states have so-called trigger laws that would automatically end Medicaid expansion if federal funding is cut: Arizona, Arkansas, Illinois, Indiana, Montana, New Hampshire, North Carolina, Utah and Virginia. Three additional states — Iowa, Idaho and New Mexico — would require the government to take cost-saving steps to ease the financial impact of federal cuts.

Alker is skeptical that Congress would be able to get such legislation passed before most state legislative sessions end this spring. But if cuts are made, the impacts could start showing up in 2026.

Regardless of possible cuts at the federal level, states including Arkansas and Idaho are looking at ways to reduce the number of Medicaid-eligible people by instituting work requirements or benefit caps.

States need federal approval to impose such additional conditions on Medicaid eligibility.

The first Trump administration approved work requirements in 13 states, but the courts later struck those down and the Biden administration rejected such requests. States, including Arkansas, are trying again, hoping they're more likely to get what they want under the new Trump administration.

Redman told Idaho legislators that he expects the Trump administration to grant the waivers that would be needed under his proposed bill.

"I actually spoke to several folks at the new federal administration, and they said they're looking for waivers that are unique and creative, that they want to grant," he said.

Meanwhile, Republican lawmakers in non-expansion states have in recent years warmed to the idea of expansion. It was arguably the biggest issue of last year's legislative session in solidly red Mississippi, and was backed by Republican Lt. Gov. Delbert Hosemann. Expansion is back on the table this year, though lawmakers have said they won't consider a plan unless it includes work requirements.

But in Alabama last month, House Speaker Nathaniel Ledbetter, a Republican, said expansion would no longer be a priority this session because Medicaid was likely to see changes at the federal level.

"I think we are better off seeing what they are going to do," he told reporters.

— Stateline is part of States Newsroom, a national nonprofit news organization focused on state policy.