Health
The Three States That Are Especially Stuck if Congress Cuts Medicaid
If congressional Republicans go through with some of the deep Medicaid cuts they are considering, three states would be left in an especially tight bind.
South Dakota, Missouri and Oklahoma have state constitutions requiring that they participate in Medicaid expansion, the part of Obamacare that expanded the health program for the poor to millions of adults.
If Republicans choose to make the projected budget reductions by cutting into Medicaid expansion, the other 37 states (and D.C.) that participate in the expansion could stop covering working-class adults. Nine states have laws explicitly requiring them to stop Medicaid expansion or make significant changes if the federal share of spending drops.
But South Dakota, Missouri and Oklahoma can’t do that. They either need to amend their constitutions, a lengthy process that can take years, or figure out how to fill the budget hole, most likely by cutting other services or raising taxes.
The constitutional amendments were put on state ballots by progressive activists, who wanted to entrench the Medicaid program in places that had been hostile to that part of the Affordable Care Act. The idea was twofold: to get health coverage to more people, and to tether more states and their Republican lawmakers to Medicaid.
The ballot initiatives passed by a wide margin, and now these states have more at stake in the congressional debate over Medicaid. Even some conservative senators, like Josh Hawley of Missouri, are speaking out against reducing funding for the program. The Republican senators from the three states with constitutional amendments could become an unlikely part of the firewall against big cuts to Medicaid.
“Expanding Medicaid anywhere protects it everywhere, which is now what we’re seeing today,” said Kelly Hall, executive director of the Fairness Project, the nonprofit that organized the constitutional amendment campaigns. She noted that her group expected the expansions would broaden support for the program in Washington.
The exact details of any cuts are still unclear, but Republicans in Congress hope to enact a detailed plan by the end of September. A budget resolution that passed the House last month called for at least $880 billion in cuts over a decade from the committee that oversees Medicaid. If all the cuts came from Medicaid, that amount would represent an 11 percent reduction in federal Medicaid spending, and millions would most likely lose coverage. The Senate passed its own budget Saturday that included the House numbers but was less clear on the scope of its preferred spending cuts.
Lawmakers and policy analysts who favor cuts argue that states no longer pay their fair share of Medicaid’s bills. In recent years, the federal share of spending on the program has grown to more than 70 percent overall from around 60 percent. The federal government pays 90 percent of the costs for working-age adults who enroll through the expansion, a high share that the architects of Obamacare meant to ease the burden of expansion from state budgets.
Because states would become responsible for what had once been paid by the federal government, the states with constitutional amendments would have especially high financial stakes. In Missouri, Medicaid funding makes up about 35 percent of the state’s entire budget. If the federal government pulled back, the state would probably have to raise taxes or cut other parts of its budget, like education or transportation.
The last time Republicans attempted major Medicaid changes, as part of their Obamacare repeal push in 2017, some Republican governors lobbied their senators to protect the program, and several voted against the bill. In the years since, seven more Republican-led states have expanded Medicaid by ballot measure, expanding coverage to 950,000 people.
Even after passing at the ballot, Medicaid expansion still faced opposition from elected officials charged with setting up the program. The former Maine governor Paul LePage went the furthest, claiming he would go to jail rather than carry out a Medicaid expansion. (The expansion was implemented after he was replaced by a Democrat.)
That resistance got the progressive activists who organized and funded the ballot initiative campaigns looking for a way to make Medicaid expansion more ironclad. For 2020, they came up with the idea of pursuing voter referendums to enshrine participation in the program in state constitutions. They succeeded in Missouri and Oklahoma in 2020, followed by South Dakota in 2022.
Those ballot initiatives took more work, requiring more signatures to get onto the ballot. Activists decided the extra hurdle was worth it to entrench Medicaid in areas of the country that had been hostile to the program — thus giving it more protection in Washington.
The politics of the Republican Party have changed since 2017, too, shifting from Tea Party austerity toward working class populism. Hospitals have also become more dependent on Medicaid as it has expanded, and more effective at arguing this point to government officials.
“The system is much more firmly in place now than it was eight years ago,” said Brendan Buck, who was an aide for Speaker Paul Ryan during the Obamacare repeal effort in 2017 and is now a partner in a communications firm that does work for health industry clients. “These are our states. These are our voters. And I think they will hear loud and clear if this does become a real threat.”
When he was Missouri’s attorney general, Mr. Hawley led two lawsuits seeking to overturn the Affordable Care Act. But in February and again this past week, he voted with Democrats on budget amendments to protect Medicaid. Those efforts were largely ceremonial. But Republicans may need his vote to advance their larger package of tax cuts and spending reductions later this year.
“Our voters voted for it — my constituents — by a decisive margin,” Mr. Hawley said of Medicaid expansion in a recent interview, noting that a fifth of the state gets health insurance through the program.
While Mr. Hawley said he would be comfortable voting to add a work requirement to the program, he was “not going to vote for cut benefits.”
Senator Mike Rounds of South Dakota has also opposed reducing federal funding for Medicaid expansion because of the financial burden it would put on states. “That’s not a cost-cutting measure — that’s a cost transfer,” he told Politico in February.
Even many blue states that passed expansion through their legislatures will probably stop Medicaid coverage for poor adults if cuts go through. Twelve states, including Illinois and Virginia, have passed legislation that would automatically rescind the expansion if federal funding dips.
The states with constitutional amendments are already beginning to prepare for the possibility of a major budget hole. In Oklahoma, for example, federal Medicaid funding makes up almost 30 percent of the state’s entire budget.
A conservative Oklahoma think tank has suggested that the state cut other parts of Medicaid to make up the gap instead of dipping into funding for services like roads or schools.
But reducing Medicaid services alone probably wouldn’t be enough to offset the lost federal funding. There are only a handful of ways states are allowed to cut the program, such as ending coverage for prescription drugs or no longer providing insurance to postpartum women.
In South Dakota, the Legislature passed a law in February that would alter the constitution to leave the program if federal funding dropped.
The new law wouldn’t immediately pull South Dakota out of Medicaid expansion but would give the Legislature the flexibility to do so. To change the constitution, voters would also need to weigh in with a new ballot initiative, scheduled for the state’s next election in 2026 — potentially after Congress passes cuts.
“I’m worried it won’t be soon enough, but that is when our next election is,” said Tony Venhuizen, who introduced the bill in January as a member of the State Legislature. “There isn’t another way.”
Catie Edmondson contributed reporting.
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As the popularity of GLP-1 drugs continues to climb, significant weight loss associated with the medications has been linked to a growing list of cosmetic concerns.
Some surgeons report that more patients are seeking treatments for so-called “Ozempic earlobes,” which reportedly appear thinner, longer or more sagging after the loss of facial fat.
“The use of semaglutides causes you to lose fat across your body, including the small, fat pads of the earlobes,” facial plastic surgeon Sachin S. Parikh, MD, told NewBeauty.
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“It’s important to note that semaglutides do not damage ear tissue or affect hearing in any way, so any intervention would be purely cosmetic,” added the California-based doctor.
Some of the potential treatments for “Ozempic earlobes” may include dermal filler, fat transfer, laser treatments or surgical earlobe reduction, according to the report.
As the popularity of GLP-1 drugs continues to climb, significant weight loss associated with the medications has been linked to a growing list of cosmetic concerns. (iStock)
Dr. Mohammed Asif from Duly Health and Care in Naperville, Illinois, said that while he hasn’t personally noticed an uptick in ear surgeries, he has seen a rise in other procedures due to GLP-1-triggered weight loss.
Some of those include panniculectomies (Ozempic skin removal surgery) and abdominoplasties (tummy tucks).
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“There has been a significant increase in body contouring procedures among patients with GLP-1 weight loss,” Asif told Fox News Digital.
“In my practice, I’ve seen a significant surge in breast lifts, panniculectomies (skin removal surgery), abdominoplasties (tummy tucks), brachioplasties (arm lifts) and thighplasties due to weight loss.”
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Healing and recovery are “far greater and less complicated” than with bariatric surgery weight loss, Asif noted.
“This is due to the gradual weight loss achieved over time with GLP-1s.”
“Ozempic breast” is another common complaint, according to Dr. Michael Omidi, a double board-certified plastic surgeon practicing in Beverly Hills.
“There has been a significant increase in body contouring procedures among patients with GLP-1 weight loss,” a doctor told Fox News Digital. (iStock)
“Women in their 30s and 40s would not typically need a breast lift, but when you’re taking drugs like Ozempic or Wegovy that cause rapid weight loss, women can see gravity take its toll on their breasts,” he told Fox News Digital.
“When women, especially younger ones, lose fat too fast, it causes the breasts, which are comprised of fat, glandular tissue and skin, to lose volume,” he went on. “The skin and supporting ligaments don’t always bouce back at the same rate as the weight loss, resulting in breasts that can appear saggy and deflated.”
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Dr. Samuel Golpanian, a double board-certified plastic surgeon in Beverly Hills, said he has seen “dozens” of patients – men and women alike – seeking treatments for so-called “Ozempic butt” after significant weight loss.
“This is an unintended consequence of taking GLP-1s,” he told Fox News Digital.
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“Such dramatic weight loss in a short period of time causes the skin not to tighten quickly enough to keep up with the body’s changes. Our buttocks have a large amount of fat, so when that volume disappears quickly, you’ll develop a flatter, saggier behind.”
“Such dramatic weight loss in a short period of time causes the skin not to tighten quickly enough to keep up with the body’s changes,” a surgeon said. (iStock)
Kristy Hamilton, MD, a Houston-based surgeon who is a member of the American Society of Plastic Surgeons (ASPS), agreed that a growing number of patients are seeking skin-tightening procedures after losing large amounts of weight with GLP-1s.
“We’re absolutely seeing more of those patients, and I expect that trend to continue,” said Hamilton in an ASPS report.
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“People are losing as much as 100 pounds on this medication – and when you’re losing that amount, that’s significant. You’re certainly going to have excess skin afterward.”
The ASPS lists the following body-contouring procedures as the ones most frequently performed after substantial weight loss.
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- Tummy tuck (abdominoplasty): Removes excess abdominal skin and fat
- Lower body lift (belt lipectomy): Addresses the abdomen, buttocks, hips and thighs
- Arm lift (brachioplasty): Removes hanging upper-arm skin
- Thigh lift: Tightens excess skin of the inner thighs
- Breast lift (mastopexy): Addresses sagging, deflated breasts after weight loss
- Facelift/neck lift: Addresses facial volume loss and skin laxity after major weight loss
“People are losing as much as 100 pounds on this medication – and when you’re losing that amount, that’s significant. You’re certainly going to have excess skin afterward.” (iStock)
Experts say adequate protein intake and resistance training can help minimize the loss of lean muscle mass that often accompanies rapid weight loss, which could reduce some of the cosmetic concerns.
Golpanian also emphasized the importance of eating enough protein.
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“It can be harder since your appetite is suppressed, but it’s so important to consume at least 110 grams of protein a day while taking a GLP-1 drug,” he advised.
“Also, I say this to my patients all the time: You have to lift weights to keep your muscles from atrophying. Strength training can help build muscles and preserve your glutes.”
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No sex for the win? This was the advice given to this year’s NBA champions.
New York Knicks owner James Dolan addressed the now-champs as they headed into the playoffs in April 2026, acknowledging their high potential to eventually win the championship.
“I don’t know if you understand what it would mean for you to win a championship this year … It would be life-changing,” he said. “It will stick with you the rest of your lives, and if you don’t win, you’ll be thinking about it the rest of your lives.”
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As Dolan’s inspirational speech to the team went on, he explained how the next 10 weeks would require each player to make sacrifices – watching their diets, getting proper sleep and perhaps even abstaining from sex.
“You need sacrifice and you need to eliminate all the distractions around you,” he said.
Jalen Brunson of the New York Knicks celebrates with the Bill Russell NBA Finals Most Valuable Player Award trophy and Knicks owner James Dolan after defeating the San Antonio Spurs in Game Five of the 2026 NBA Finals at Frost Bank Center in San Antonio, Texas, on June 13, 2026. (Gregory Shamus/Getty Images)
“I had this idea that maybe you should give up sex for the next 10 weeks,” the owner said. “You don’t have to give up sex for the next 10 weeks – but, like the Spartans … They denied themselves, so that they can have an edge. Get the edge.”
This received a few snickers from the team, and Dolan responded, “Don’t tell [your wives and girlfriends] you’re not going to have sex and don’t tell them it was my idea. But let them know what this is going to be like … and how they’re going to have to sacrifice, too.”
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Dr. Anna Elton, licensed marriage and family therapist and clinical sexologist in Massachusetts, confirmed that this belief has been around for centuries, dating back to the ancients Spartans and early Olympic competitors.
Avoiding sex can preserve energy, increase aggression and sharpen focus, according to Elton.
The theory behind abstaining from sex for better athletic performance supports that it can preserve energy, increase aggression and sharpen focus. (iStock)
But modern research has found little evidence that consensual sexual activity negatively impacts strength, endurance, reaction time or athletic performance when it occurs at least 10 hours before competition, the doctor countered.
However, “activity very close to competition may affect recovery measures,” she added. What may be more important, according to Elton, is the psychological value of abstinence.
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“Choosing to abstain can reinforce discipline and total commitment to a larger goal,” she said. “In those cases, the advantage may come more from mindset and focus than from any physical effect.”
“Whether the sacrifice is alcohol, social activities, favorite foods or sex, the message is often the same: ‘We are all in.’”
New York Knicks guard Jalen Brunson celebrates with teammates after the Knicks defeated the San Antonio Spurs in game five of the 2026 NBA Finals at Frost Bank Center in San Antonio, Texas, on June 13, 2026. (Geoff Burke/Imagn Images)
The science of abstinence
This discussion has historically focused on men, which Elton said is often based on “misconceptions about testosterone and energy depletion.”
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“Research has not demonstrated that normal sexual activity causes a meaningful decline in athletic performance, and concerns about testosterone depletion have not been consistently supported by the evidence,” she said.
“For women, sexual activity may have additional benefits related to stress reduction, emotional regulation and relationship satisfaction.”
Abstaining from sex for athletic performance may create a sense of discipline, minimize distractions, maintain focus on training and reinforce a team culture centered on sacrifice and commitment, experts say. (iStock)
In a separate interview with Fox News Digital, Dr. Anthony Puopolo, a men’s health expert and lead medical provider for RexMD, echoed Elton’s assessment that research largely does not support abstinence as a performance enhancer.
This is despite a small amount of evidence that suggests engaging in sexual activity within two hours of competition could pose a risk to cardiovascular recovery.
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“Unfortunately, nearly all studies (99%) have been conducted in males aged 20 to 40, so there is virtually no data on female athletes, older athletes or diverse populations,” said the Puerto Rico-based expert. “We know what to tell the Knicks, but we are not sure what to recommend for the New York Liberty.”
Importance of connection
Elton said abstinence may still offer psychological benefits for some competitors. “For some athletes, it can become part of a pre-competition ritual that enhances confidence,” she told Fox News Digital.
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Some other potential benefits of sexual activity include stress reduction, improved sleep, mood enhancement, emotional connection with a partner and relief from performance-related tension.
“Strong, supportive relationships are associated with better psychological resilience, which can be valuable during high-pressure competitions,” Elton said.
“One of the most overlooked performance advantages may be having a supportive relationship waiting at home,” a doctor said. (iStock)
“Ultimately, there is no universal rule,” she went on. “What helps one athlete perform at their best may not help another.”
Elton stressed that sleep, recovery, nutrition, stress management and support from loved ones are universal performance boosters.
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“Athletes devote tremendous attention to training their bodies, while overlooking the importance of their personal relationships,” she cautioned. “A supportive partner can be one of the greatest assets during a demanding season.”
“If competition requires temporary sacrifices, make those decisions together and keep communication open.”
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