W hen the Affordable Care Act (ACA) was passed in 2010, one of its cornerstone provisions was the expansion of Medicaid eligibility.

This move allowed millions of low-income adults , especially those who didn't qualify for traditional Medicaid and couldn't afford private insurance, to gain access to health coverage.

Congress could jeopardize health care for millions of Americans

Since 2014, 40 states and Washington D.C. have embraced this expansion, extending coverage to an estimated 21 million Americans and contributing to a historic decline in the uninsured rate nationwide.

Under the expansion, the federal government covers 90% of the cost, a more generous contribution than the typical 57% match for other Medicaid recipients .

Supporters argue this has saved lives and strengthened communities by making healthcare accessible to working-class adults.

Critics, however, say the costs have ballooned and the scope has gone too far.

With Republicans back in full control of Congress and Donald Trump in the White House, this longstanding policy is once again in the crosshairs.

Three states- South Dakota, Missouri , and Oklahoma -are facing a uniquely difficult dilemma.

Their state constitutions mandate participation in Medicaid expansion , making it nearly impossible to walk away from the program, even if Congress cuts federal funding.

These constitutional amendments, passed by voters via ballot initiatives, were designed to lock in the expansion in historically resistant states.

The gamble worked, but now it's creating a new set of challenges.

If Congress moves forward with its proposed Medicaid cuts , potentially slashing up to $880 billion over the next decade, these three states can't just opt out like others with "trigger laws."

Instead, they would either need to amend their constitutions, a complex and time-consuming process, or make up the funding shortfall through painful trade-offs.

That could mean raising taxes or slashing spending in other critical areas like education and transportation.

With more than 3.7 million people currently relying on the expansion programs in these three states, the stakes couldn't be higher.

Even some Republican lawmakers from these regions are pushing back, wary of the political and economic fallout.

As the budget fight heats up in Washington, the future of Medicaid , and millions of lives, hangs in the balance.