President Trump’s big legislative ambition — extending his signature tax cuts — may have just crashed into his newly expressed wish to protect the Medicaid program.
Mr. Trump said Tuesday night on Fox News that he wouldn’t make cuts to Medicaid, the federal-state health insurance program that mostly covers poor Americans. But making substantial cuts to Medicaid is a key part of congressional Republicans’ plan to extend the tax cuts.
“Medicare, Medicaid — none of that stuff is going to be touched,” Mr. Trump said in an interview with Sean Hannity. “We won’t have to.”
Mike Johnson, the House Speaker, has been hard at work on a major bill that can balance various priorities of Mr. Trump and his caucus: a desire for $4.5 trillion in tax cuts, a wish to trim federal spending, and concerns about rising federal debts.
The budget Mr. Johnson negotiated, a first step in passing that agenda, calls for around $880 billion in cuts to Medicaid, in an effort to counterbalance a portion of the tax cuts.
Mr. Trump’s comments may make that carefully negotiated package moot.
Mr. Trump has long promised not to make major changes to Medicare, the public health care program for seniors and people with disabilities. But he has always been more open to changes to Medicaid, which has become the biggest health insurance program in the country.
During his first term as president, he supported an Obamacare repeal effort that would have cut around $800 billion from Medicaid and permanently altered the structure of the program.
His presidential budgets also included major cuts and structural changes to Medicaid.
But as the failure of the Obamacare repeal effort highlighted, Medicaid has become a widely used and popular program, covering 72 million Americans. Federal funding for Medicaid has also become a cornerstone of state budgets, meaning Medicaid cuts would put fiscal pressure on Republican governors, not just poor patients who need help paying for their health care.
Medicaid covers nearly half of all births in the country, and around two-thirds of nursing home stays. In 41 states that expanded the program as part of the Affordable Care Act, it also covers millions of working-class Americans with incomes close to the poverty line.
The House plan remains vague. It does not specify Medicaid policies other than the budget target for the committee that oversees the program. But spending reductions so large would require major changes. Adding a work requirement to the program, a proposal with some public support, would save only around $100 billion.
Steve Bannon, Mr. Trump’s former chief strategist, has been warning publicly that cuts to Medicaid could be politically damaging to Mr. Trump and other Republicans. “A lot of MAGA’s on Medicaid,” he said on his “War Room” podcast last week. “You can’t just take a meat ax to it.”
And a handful of Republican lawmakers, including a few in the House whose votes Mr. Johnson will need, have begun expressing reservations about big changes to Medicaid.
Mr. Trump followed up his comments Tuesday night with a post on social media Wednesday endorsing the House framework. “House Resolution implements my FULL America First Agenda, EVERYTHING, not just parts of it!” he wrote.
The trouble is that the math of the Republican budget plan requires major cuts to the Medicaid program. Extending expiring tax cuts passed in 2017 — a major congressional and presidential priority — will alone increase federal deficits by more than $4 trillion over a decade. At a time of growing federal debt, many Republican lawmakers say they won’t vote for such a large increase. A recent amendment added to the House bill requires lawmakers to find $2 trillion in spending cuts to help compensate for some of the lost revenue.
And Mr. Trump has already taken other large federal programs off the table. In addition to Medicare, which he has vowed not to cut, he has promised to avoid changes to Social Security. The House budget bill increases, rather than shrinks, the next largest category of federal spending, the military.
And because Congress wants to pass the package using a special budgetary process to avoid a Senate filibuster, its cuts are subject to a detailed set of rules and restrictions, further limiting legislative options.
In the current House plan, Medicaid cuts make up nearly half of the required $2 trillion in spending cuts. Hitting the target without them would mean revising the bill’s language as well as enormous cuts to remaining programs.
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