While President Trump has been busy with his executive branch rampage, congressional Republicans have been pursuing a plan to extend and enlarge Mr. Trump’s 2017 tax cuts, which favor the richest Americans.
But the math is stubborn, particularly since Mr. Trump has repeatedly pledged to avoid cuts to Medicare and Social Security. And that has put Medicaid, the federally subsidized program run at the state level that provides health insurance or long-term care coverage to more than 70 million Americans, in the G.O.P.’s sights — even though Mr. Trump said this month that Medicaid, too, wouldn’t be “touched.”
On Tuesday, House Republicans took the first step toward Medicaid cuts by passing a budget resolution that could mean up to $880 billion in cuts to Medicaid over 10 years. Now they have to actually identify specific cuts to the program — deciding which patients, providers and state governments will lose, and how much.
Republicans are fooling themselves if they think it will be easy. Gutting Medicaid means attacking a program backed by a wide range of organizations — from the AARP to the American Hospital Association — that also enjoys broad public support. Even longtime Trump ally Steve Bannon recently warned: “A lot of MAGA’s on Medicaid,” adding, “just can’t take a meat ax to it, although I would love to.”
The federal government spends around $600 billion a year on Medicaid. It reimburses states for at least 50 percent of program costs. (Rich states like New York and California typically get 50 percent, while some poor states, like West Virginia and Mississippi, get over 70 percent.)
Significant cuts to this funding would send fiscal shock waves through state governments across the country as billions of dollars in federal funding stopped flowing, forcing states to decide where and how to cut their Medicaid programs — whether to eliminate coverage for some beneficiaries, reduce payments to physicians, deny home care to some seniors or raise state taxes to make up the difference.
This isn’t the first time Medicaid has faced attacks. The program was created, alongside Medicare, in 1965, and by the 1970s, some observers were already predicting its demise. In the early years, the program was sometimes stigmatized as “welfare medicine.” Many liberals saw it as a poor substitute for universal health care; many conservatives didn’t like the program’s rising costs. In both the 1980s and the 1990s, Republicans made attempts at turning Medicaid into a block grant program — giving states a fixed amount of money, putting the burden of increased costs on them and capping federal expenditures.
Medicaid not only survived these efforts, it has expanded, including to more children through the closely related Children’s Health Insurance Program, known as CHIP. Medicaid expansion was at the heart of the Affordable Care Act — Obamacare — helping cut the percentage of America’s uninsured people roughly in half, to around 8 percent in 2023.
Once considered a poor people’s program, Medicaid has proved itself a political juggernaut. Why? Start with the money. The Medicaid program spends about $900 billion a year in state and federal funds, paying for close to one-fifth of health care expenditures in the United States. The program is the primary payer for almost two-thirds of nursing home residents and funds just over 60 percent of long-term care.
Hospitals have an obligation in many instances to provide care even when patients can’t pay. Significant Medicaid cuts would almost certainly leave hospitals to provide more uncompensated care. Many medical facilities, particularly in low-income and rural communities, could be at greater risk of closing. That’s among the reasons the hospital industry has supported Medicaid expansion and opposed cuts at the state and federal levels.
Hospitals are politically influential. According to OpenSecrets, in 2023 and 2024, the hospital and nursing home industries accounted for $62 million in political contributions. And hospitals are major employers: Indiana University Health has about 36,000 employees and Prisma Health in South Carolina has 29,000 employees.
If they vote to cut Medicaid, Republicans probably won’t just face opposition from patient advocates and liberal do-gooders. They’ll very likely hear from the board members and executives of major employers in their districts.
They’re also very likely to face opposition from another constituency: older voters and voters who have family members with disabilities. Medicare generally doesn’t pay for nursing homes and home care for elderly and disabled Americans; Medicaid does. Medicaid also helps pay Medicare premiums and co-pays for low-income seniors through Medicare Savings Programs. And it funds a substantial portion of supportive services for the intellectually and developmentally disabled.
Low-income seniors may not sound like a powerful constituency, but many people who benefit from Medicaid long-term care coverage don’t start out as low-income. Nursing home care can easily cost $100,000 a year; many middle-class families who start out paying out of pocket will find that their loved ones become eligible for Medicaid in short order. That means there is a broad middle-class constituency, including Republican voters, that relies on Medicaid-funded long-term care.
Medicaid is crucial to state budgets — including in red states. On average, when federal funds are included, Medicaid represented 28.8 percent of states’ budgets in 2022. Even a relatively limited federal cutback could present many states with fiscal crises. Some red-state governors would very likely push back against cuts that might force them to make an unpopular choice between cutting their Medicaid programs or raising taxes.
Blue-state Republicans might balk as well: A Medicaid cut might be a tough sell for the seven Republicans from New York and nine from California helping to prop up Republicans’ three-vote House majority.
Republicans might find all these sources of opposition — provider lobbies, Medicaid beneficiaries, Republican governors, blue-state Republicans — more manageable if the public supported their larger goal of shrinking Medicaid. But far from supporting Medicaid cuts, voters — even those in deep-red states like Idaho, Missouri and Oklahoma — have voted for Medicaid expansion by ballot initiative. A 2024 KFF poll found that 71 percent of adults think that Medicaid should largely continue as it is today, and 66 percent of adults in (overwhelmingly Republican) non-expansion states support expansion. A Pew Research Center poll recently found that 65 percent of Americans think that “it is the federal government’s responsibility to make sure all Americans have health care coverage.”
That’s among the reasons Republicans’ last major push to cut Medicaid spending, in 2017, fell apart. In 2016, Mr. Trump and Republicans ran on rolling back the A.C.A., but the bottom fell out of their effort when the Congressional Budget Office estimated that the Republican plan would increase the number of people without health insurance by more than 20 million in a decade. The effort to repeal the A.C.A. stumbled on for several more weeks before Senator John McCain famously put it out of its misery.
There’s little evidence the public’s views on this issue have changed since. Republicans hoping to slash Medicaid for the sake of tax cuts do so at their peril.
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