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.
Every day we’re faced with a zillion small choices: Go to sleep early, or watch one more episode of that Netflix drama. Call an old friend to catch up, or cruise social media. Of course, no single action will guarantee a long, healthy life or doom you to an early grave. But those little daily decisions do add up, and over the long term they can make a difference when it comes to both your longevity and your health span, the amount of life spent in relatively good health.
Scroll through this theoretical “day in the life” and select the option that best fits your typical day. Not every situation will apply perfectly, but think about which choice you’d be most likely to make. This isn’t a formal scientific assessment. The goal here isn’t to assign you a “good” or “bad” score, but to help you understand the central factors that shape the way we age and how long we live.
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A study from Harvard Medical School indicates natural selection has favored the red hair gene, resulting in a potential increase in the number of redheaded people as humanity continues to evolve.
By analyzing nearly 16,000 ancient genomes spanning 10,000 years, researchers identified a list of traits that nature is actively pushing forward. Among the most prominent were the genetic variants for red hair.
“Perhaps having red hair was beneficial 4,000 years ago, or perhaps it came along for the ride with a more important trait,” the authors noted.
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The study, published in the journal Nature, relied on a large database of ancient DNA from West Eurasia. Using new computing methods, the team was able to filter out random fluctuations in DNA to identify what it called “directional selection.”
Directional selection happens when a particular version of a gene gives an organism a strong survival or reproductive advantage, causing it to become more common in a population faster than it would by chance, according to experts.
Directional selection is when a specific gene provides such significant benefits that it rises in frequency across a population much faster than random chance. (iStock)
Prior to this study, scientists only knew of about 21 such instances in human history, one of which was lactose tolerance. This new research uncovered hundreds more.
“With these new techniques and a large amount of ancient genomic data, we can now watch how selection shaped biology in real time,” Ali Akbari, first author of the study and senior staff scientist in the lab of Harvard geneticist David Reich, said in a press release.
COMMON EATING HABIT MAY TRIGGER PREMATURE IMMUNE SYSTEM AGING, STUDY FINDS
The data showed that genetic markers for red hair are among 479 gene variants that have been strongly favored over the past 10,000 years. One likely explanation, the researchers said, is a major shift in human history: the transition to farming.
Scientists have long pointed to vitamin D synthesis as a likely driver for the rise of traits like fair skin and light hair. (iStock)
As humans moved away from hunting and gathering and settled into agricultural societies, their environment and behavior changed radically, triggering an evolutionary “acceleration.”
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While the Harvard study provides the first definitive statistical proof that red hair was actively selected during the rise of farming, the researchers noted that the exact prehistoric benefit still requires more study.
However, scientists have long pointed to vitamin D synthesis as a likely driver for the rise of these light-pigmented traits in northern climates.
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While redheads remain a minority of the global population today, the Harvard study’s analysis suggests that they may not be an evolutionary accident.
While redheads remain a minority of the global population today, the Harvard study’s analysis suggests they may not be an evolutionary accident. (iStock)
Instead, the red hair trait was “boosted” by natural selection as humans adapted to the challenges of a modern world, according to the researchers.
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The researchers urged caution in how these findings are interpreted.
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“What a variant is associated with now is not necessarily why an allele propagated,” the authors noted.
Dr. Megan Jack, a neurosurgeon in Cleveland, often works 60 or 70 hours a week. And she’s completely unavailable when she’s in the operating room. That makes it tough to be a caregiver for her 76-year-old mother, who lives in a separate unit on Dr. Jack’s property, 30 minutes away from the hospital.
To help care for her mother, who has Alzheimer’s disease, Dr. Jack uses an array of high-tech tools, some of which didn’t exist just a few years ago. She manages her mother’s medications with a smart pill box. She changes her television channels with an app, sends appointment reminders through a digital message board — and, with her mother’s blessing, uses cameras for communication and monitoring.
“It’s been invaluable that I can both make sure she’s safe and make sure everything is going well,” Dr. Jack said, “but also give her the independence and the freedom that she still deserves.”
America is aging rapidly. Roughly 11,000 people are turning 65 each day in the United States. And many of them — 75 percent of people over 50, according to AARP’s most recent survey, from 2024 — hope to spend their remaining years in the comfort of their homes, rather than in assisted-living or other care facilities.
One thing that could help fulfill those wishes is the budding field of “age tech,” which encompasses tools that support older adults. Industry experts say that age tech is making homes safer for older adults and is easing the minds of their caregivers, especially those who live far away or work outside the home.
Dr. Jack said that age tech had “really allowed me to integrate caregiving into my life, as opposed to caregiving taking over my life.”
The age tech boom
If older adults don’t have loved ones who are both close by and able to help, they might believe they don’t have a ton of options. They can live independently, or, if they can afford it and qualify medically, they can move to an assisted-living facility or a nursing home, without a lot of choices in between. In-home help can be expensive without Medicaid and can also be difficult to find, given the serious shortage of home care workers.
Age tech can help bridge some important gaps, said Emily Nabors, the associate director of innovation at the National Council on Aging, a nonprofit advocacy group. Already, AARP reports that 25 percent of caregivers are remotely monitoring their loved ones with apps, videos or wearables, nearly double the percentage from five years ago.
“We used to say homes are the health care settings of the future, but they really are health care settings now,” Ms. Nabors said. “Aging in place is very realistic.”
More than 700 companies are in AARP’s AgeTech Collaborative, a group that connects businesses, nonprofits and funders to help get new technologies off the ground. Altogether, the collaborative’s start-ups have raised nearly $1 billion in the past four years.
The products include smart walkers, glasses with lenses that provide real-time captions of conversations for those with hearing issues, and a concierge service that connects older people to drivers and deliveries, even if they don’t have a smartphone.
Ms. Nabors does foresee some affordability and access barriers to age tech, including the lack of high-speed internet in rural areas, but she said one vital resource would be local aging agencies, which can offer advice and, sometimes, free support.
Janet Marasa leaned on the agency near her home in Rockland County, N.Y., to get a free robotic pet for her mother, Carol DeMaio, 80, who has dementia. The pets, manufactured by a company called Joy for All, aim to offer emotional support without the upkeep.
Ms. DeMaio named the robotic dog Sabrina, after a golden retriever who died. The new Sabrina stays at the foot of her bed at night. As soon as Ms. DeMaio stirs awake, the dog reacts. “She said it gives her a reason to get up in the morning,” Ms. Marasa said.
The dog has been a boon to her, too. “It provides comfort and interaction that I can’t provide every second,” said Ms. Marasa, who lives with her mother but works full time for the county government. “It gives her something that she can feel like is totally her own.”
In Broward County, Fla., where the population of residents over 85 is expected to nearly triple over the next few decades, the local agency on aging has used state and federal money and private grants to provide technologies to nearly 4,000 of the county’s seniors at no cost.
Its offerings include a company that uses radar to sense falls and a program that allows seniors to make video calls through their televisions.
“The possibilities are endless,” Charlotte Mather-Taylor, the agency’s chief executive, said. “It’s pretty great to see all the new technology coming out so quickly, and I think that can only benefit our older population and also our caregivers.”
Here comes A.I.
Even technologies not specifically marketed as age tech can help older adults maintain their independence, said Laurie Orlov, founder of the blog Aging and Health Technology Watch. She pointed to video-calling and telehealth platforms; remotely controlled thermostats and lights; and smart speakers, doorbells and watches.
“All technology can be customized to help older adults stay longer in their homes and help their family members feel good about it, or at least tolerate it,” Ms. Orlov said.
That will only become more true with the continued proliferation of artificial intelligence, Ms. Orlov added. Some older adults are already using conversational A.I. to get answers about things like the weather or their medications. (Relying too heavily on A.I. can, however, have negative consequences because chatbots often give flawed medical advice and can lead patients astray.) A.I. can also assist in pattern detection: alerting caregivers to signals that might indicate declines in someone’s cognition or mental health, such as changing their speech pattern or leaving the house less frequently.
One A.I.-powered age tech tool is ElliQ, a tabletop companion robot that looks like a sleek silver desk lamp with a screen. About a year and a half ago, Camille Wolsonovich got one for free, thanks to a local nonprofit, for her 90-year-old father, Bill Castellano. He lives alone in a senior community.
Ms. Wolsonovich, who runs a consulting business, relies on ElliQ to lead her father in exercises and remind him to take his pills and drink water. The robot also asks her father about his sleep and mood via automated check-ins.
“Everything’s just another layer that gives us more confidence, from a caregiving standpoint, that he’s good,” Ms. Wolsonovich said. “I don’t have to necessarily track everything all the time and be overbearing.”
As for Mr. Castellano? He plays trivia digitally and converses daily with ElliQ. The robot, which has a friendly female voice, asks questions, cracks jokes and remembers his likes, dislikes and friends. “She’s great company,” he said. “Everybody around me wants one.”
What about ethical concerns?
Clara Berridge studies the ethics of age tech at the University of Washington.
She has many privacy concerns, namely that most direct-to-consumer products aren’t subject to medical privacy laws, despite being privy to sensitive health information. Though she hopes the federal government will eventually step in to regulate these products, as it has in other countries, the onus remains on the consumer for now.
And even if an age tech product isn’t selling mom’s personal data to the lowest bidder, Dr. Berridge said there’s still the question of whether certain tools are ethical.
“It’s really important for caregivers to recognize that using these new technologies that give them more information about someone can represent greater intrusion into someone’s life,” she said.
What may be well-intentioned monitoring could reveal information that an older adult would rather keep private, such as issues with incontinence, or the comings and goings of a romantic partner.
“It can lead to somebody feeling infantilized,” Dr. Berridge said. “Like there’s not a place to hide within your own home.”
Her research shows that adult children often underestimate how much their parents can understand about technology and how much they want to be involved in tech-related decisions.
She encouraged caregivers to have transparent conversations about privacy implications and to avoid ultimatums or the idea that any decision must be permanent. She said caregivers should put themselves in their parents’ shoes: Is this something they’d want their own children monitoring?
Dr. Berridge is working on an advanced directive for technology, which outlines older people’s wishes for how technology is used in their care. Ultimately, she hopes that questions about age tech will become a standard part of planning for the future.
“If you’re at the start of what, for many people, ends up being a long road of supporting someone potentially through the end of their life,” she said, “seeking to understand each other’s concerns and priorities better is time very well spent.”
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