President Barack Obama’s signature achievement, the 2010 expansion of health insurance known as Obamacare, has proved successful and popular. More than 45 million Americans have health insurance today as a direct result of the legislation. And most Republican politicians have stopped openly campaigning to kill the program.
But make no mistake: The big domestic policy bill that Republicans are trying to push through Congress is an effort to reverse the progress of the past 15 years. Despite their claims of having become a working-class party, Republicans are seeking to take away health insurance from millions of Americans, and they are doing it to give billions of dollars in tax cuts to the wealthy.
The most important attempt to undermine Obamacare is also the most cleverly disguised. To restrict access to Medicaid — the federal program that Obamacare expanded and that covers medical costs for lower-income people, including children, the elderly and people with disabilities — House Republicans are proposing to add a work requirement to the program. The proposal would strip Medicaid benefits from working-age adults who do not have children unless they can prove they are working at least 80 hours a month. That would result in 7.7 million Americans losing health insurance by 2034, according to the Congressional Budget Office.
Proponents describe it as a common-sense measure to encourage work and prevent mooching off the government. They insist it is substantively different from cutting Medicaid funding. Senator Josh Hawley of Missouri, for example, has described outright cuts as “morally wrong and politically suicidal,” but he says that he is in favor of work requirements.
We are sympathetic to the idea that some government benefits should be tied to employment. People benefit from working, and society benefits when more people are working. But health care is the wrong target. All Americans deserve access to affordable health care. Every other developed nation already ensures universal access, and the expansion of Medicaid under Obamacare, while flawed and inefficient, has brought the United States closer to that goal. Republicans are not proposing to fix the flaws. They are not proposing to deliver better health care at a lower cost. The bill would save money by depriving Americans of health insurance.
Furthermore, the evidence suggests that work requirements don’t work. Federal law already allows states to impose Medicaid work requirements in some situations, and Arkansas briefly did during the first Trump administration. Subsequent studies found no resulting increase in work force participation. Most of those subject to the work requirements already were working, and the termination of benefits did not address the reasons the remainder were not.
The primary effect of the Arkansas program was to strip Medicaid from people who were eligible. The work requirement was mostly a paperwork requirement. It punished people for failing to fill out forms. Two-thirds of those who lost coverage in Arkansas were victims of red tape, according to the Center on Budget and Policy Priorities, a progressive think tank.
Luke Seaborn is a case study. He is a 54-year-old auto mechanic in Georgia, another state that introduced a Medicaid work requirement, and he initially obtained insurance through the program. Over the past year, he has worked steadily but lost his insurance twice because of paperwork problems, according to ProPublica. “I did what I was supposed to, but that wasn’t good enough,” he said.
The problems extend beyond paperwork. A work requirement can deprive people of health insurance if they lose work through no fault of their own or if they are unable to obtain enough work. The loss of health care can then make it harder for them to find a new job. Insurance helps to keep workers healthy. Studies show that people with health insurance work more and are significantly more productive. Republicans are right to say that America should increase labor force participation. If they want to help make that happen, they should push legislation to make health insurance cheaper and more widely available.
The expansion of Medicaid has been one of two main ways that Obamacare has helped Americans get health insurance. The other has been the creation of marketplaces selling subsidized private insurance for people who are not covered through their jobs. In 2021, Congress built on Obamacare’s framework by increasing the insurance subsidies, bringing coverage within reach of millions of additional American families. The Republican plan would reverse that progress, too. It would not extend the subsidies, which are scheduled to expire in the fall. The money would be used for tax cuts.
Republicans are also proposing to impose other limits on the exchanges, such as by reducing the annual enrollment period by one month. The stated purpose is to reduce fraud. The effect would be to reduce access to health care. The changes to the exchanges would probably deprive an additional six million people of health insurance.
All told, the number of Americans living without health insurance would increase by at least 13.7 million, or more than 50 percent, by 2034, according to the Congressional Budget Office.
It is easy to get lost in the complexities of America’s health care system, but understanding the current debate doesn’t require any mastery of the details. The legislation that Republicans are pushing through Congress does not include any substantive proposals to improve the current system. The question on the table is whether the government should take health insurance from millions of lower-income Americans and give the savings to the wealthiest Americans.
We are heartened that the Republican plan is so unpopular that members of the party have tried to claim that they oppose cutting Medicaid. Last month a dozen House Republicans signed a letter expressing their “strong support for this program that ensures our constituents have reliable health care.” Medicaid cuts, they pointed out, would “threaten the viability of hospitals, nursing homes and safety-net providers nationwide.” And President Trump recently said, “We’re not cutting Medicaid, we’re not cutting Medicare, and we’re not cutting Social Security.”
But the bill that the House passed by a single vote on Thursday morning and that now heads to the Senate would indeed cut Medicaid and deny health care to millions of Americans. Word games do not change that reality.
Graphic by Aileen Clarke.
Source photograph by doomu, via Getty Images.
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