Appearing on Fox News, the Republican chair of the House Ways and Means Committee, Jason Smith, noted the need for Medicaid “cuts,” but then quickly corrected himself: “Medicaid reforms, I should say.” The Freudian slip highlighted the impossible political situation he and his fellow Republicans are in. It’s hard to imagine a path to extend President Trump’s tax breaks for the wealthy without slashing Medicaid — but most Americans, including the Republicans’ own voters, are opposed to restricting benefits.
To control the political damage, Republicans are pursuing a strategy to reduce benefits, while pretending otherwise. They’ve mostly abandoned transparent cuts, such as eligibility changes or spending reductions to states, because it’s easy for voters to understand that damage. Instead, Republicans are opting for opaque cuts, which will shed millions of eligible beneficiaries by overwhelming them with pointless paperwork and other needlessly complicated administrative requirements.
The proposed House bill reverses what has been a quiet revolution in Medicaid — making it easier for people who are eligible to obtain benefits. Over the past 15 years, reforms have included simplifying applications, eliminating confusing paperwork and automating processes, especially when it comes to renewing benefits. Surveys show that the public supports such service improvements.
In short, America has not only expanded who is eligible for Medicaid, but also made it easier for eligible people to get benefits. The eligibility expansions, which led to large increases in enrollment and spending, were so effective because they were paired with burden reductions. For example, allowing children to stay continuously on Medicaid for 12 months, rather than six months, may have halved the number of eligible children who erroneously lose coverage. During the Trump administration, some states added new barriers, which caused a nearly 6 percent loss in coverage among children within six months.
Democrats learned that addressing these easily overlooked administrative burdens was essential to ensure that more Americans have health insurance. Republicans learned a different lesson. Precisely because they’re overlooked, administrative burdens are an excellent political tool to accomplish unpopular policy goals. Consequently, Republicans are proposing to increase burdens to ensure large coverage loss among the eligible.
Work requirements have received the most attention, with much of the criticism focused on the ethics of cutting costs by making health care access contingent on employment. But those debates are a distraction from Republicans’ actual goal: pushing eligible people off the program. If you account for Medicaid beneficiaries who are already working — and those excluded from work requirements because of disability or caregiving responsibilities — almost no one should lose coverage. But when Arkansas adopted work requirements in 2018, nearly all of the people who lost coverage had met the requirements. They simply couldn’t manage the paperwork to prove it.
Digging deeper into the bill, the pattern of using burdens to quietly kick off eligible beneficiaries becomes undeniable. The bill would pause a series of comprehensive new rules, issued by the Biden administration, to make it easier for people to navigate Medicaid’s eligibility and renewal processes. The mixture of reforms would have ensured that millions of people who were eligible for benefits, including disabled people, actually received them.
The Republicans’ bill would also require more beneficiaries to renew their coverage twice a year. Since the passage of Obamacare, most people have had to repeat this process only annually. Not only would the twice-a-year requirement cost people a lot of additional time and effort, many eligible people would lose coverage during this process. By some estimates, one-third of people who lose Medicaid quickly regain it, signaling they lost it because of procedural mistakes rather than becoming ineligible. That is why recent reforms have lengthened periods between renewals.
Another new burden would require beneficiaries to pay when they go to the doctor. Co-pays reduce health care use, but do not produce cost savings. One study found that even a $12.50 co-pay discouraged women from getting a mammogram. Moreover, there’s evidence that some of the people needing health care the most are among the most likely not to get it.
Finally, congressional Republicans want to create incentives for states to add even more administrative burdens. They’re planning to increase penalties for states that make enrollment errors, which would encourage them to add excessive documentation requirements. Given that the vast majority of fraud and wasteful spending is perpetrated by private health insurers that contract with Medicaid or health care providers, the effect would be to push eligible people off the program more than it reduces any erroneous payments.
Republicans claim that such burdens serve virtuous policy goals, like reducing fraud and welfare dependency. But if millions of people are going to lose access to health insurance, let’s at least be honest about how this is likely to play out and why Republicans are pushing this agenda. The push to make public health insurance less accessible is driven not by concerns about what best serves the public. Instead, the most vulnerable will be made worse off, all to fund a tax cut that most benefits the rich.
Pamela Herd (@pamherd.bsky.social) and Donald P. Moynihan (@donmoyn.bsky.social) are professors at the Ford School of Public Policy at the University of Michigan and the authors of “Administrative Burden: Policymaking by Other Means.” They write about public policy at Can We Still Govern?
Source photograph by Liudmila Chernetska/Getty Images
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