Low-income Americans would lose health coverage and government food assistance on an unprecedented scale under the giant Republican policy bill, according to outside analysts.
But to hear President Trump and Republican lawmakers describe the bill as it nears a vote in the Senate, it cuts no benefits at all.
“We’re cutting $1.7 trillion in this bill, and you’re not going to feel any of it,” Mr. Trump said Thursday at the White House.
That claim rests on a maneuver embedded throughout the sprawling legislation: Instead of explicitly reducing benefits, Republicans would make them harder to get and to keep. The effect, analysts say, is the same, with millions fewer Americans receiving assistance. By including dozens of changes to dates, deadlines, document requirements and rules, Republicans have turned paperwork into one of the bill’s crucial policy-making tools, yielding hundreds of billions of dollars in savings to help offset their signature tax cuts.
“A lot of currently eligible people are actually going to lose benefits,” said Pamela Herd, a professor of public policy at the University of Michigan, who studies the effects of administrative burdens. “Not because they’re ineligible, but because they can’t handle the set of massive roadblocks Republicans are putting in their way.”
Here are a few specific examples of new tasks people would be asked to complete if the bill became law:
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Instead of allowing states to use existing information to verify citizenship and income for people trying to qualify for Obamacare subsidies, those individuals would be required to submit documents and would have less time to apply.
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Individuals using Medicaid would need to prove they are eligible for the program twice a year instead of annually.
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“Able-bodied” Americans aged 60-64 on food assistance would be required for the first time to meet work requirements.
A Republican plan originally in the bill that would have erected new bureaucracy for the earned-income tax credit — requiring low-income families to prove the eligibility of their qualifying children every year — was removed from the legislation after the Senate parliamentarian said it violated Senate rules.
Republican leaders have said the only people who would be excluded by these rules are fraudsters, illegal immigrants or those who don’t truly qualify.
But in each of these cases, the Congressional Budget Office has estimated that the changes would result in broad reductions in enrollment and benefits. That is, in effect, where the savings come from.
Nearly a dozen changes to the Obamacare enrollment process in the House bill are estimated to reduce insurance coverage by around four million people. More than seven million people are estimated to lose Medicaid because of a series of administrative requirements, including the twice-a-year renewals and a new program that would require poor adults to prove to state officials that they are working a minimum number of hours. An expansion of work requirements in the Supplemental Nutrition Assistance Program is expected to mean that about three million fewer people will receive aid.
“The Republicans decided on the talking point that they wanted to say, ‘We didn’t cut anyone’s benefits,’” said Diane Whitmore Schanzenbach, a professor at Northwestern who studies food assistance. “So instead they’re going to say, ‘Well, we’re going to really squeeze folks that we think should be working.’”
The Trump administration has prided itself on deregulation, cutting rules for business processes throughout the government. But when it comes to antipoverty programs, this agenda moves in the opposite direction, making individuals work harder to prove they qualify for government programs. Federal and state agencies would also need to build vast new bureaucracies to measure and monitor the new paperwork.
Republican lawmakers, White House officials and researchers who advise them argue that the extra paperwork and processes are a way of ensuring that only the truly worthy can access government help.
“If you’re going to be on the public wagon, you have to do something to help pull it, if you’re able,” House Speaker Mike Johnson said last month in a CNN interview, in which he said Republicans “are not cutting Medicaid.”
The bill does make some direct cuts to Medicaid funding, but most of its health care savings come from administrative changes. That’s a significantly different strategy from the Republicans’ attempt to repeal Obamacare in 2017, which would have directly reduced federal spending on health programs, and was thus easier for opponents to attack.
But Democrats are trying. Chuck Schumer, the Senate’s Democratic leader, has said tens of millions of Americans would be “mummified in new red tape.”
Decades of evidence show that administrative barriers prevent vulnerable families from receiving benefits, while simplifying programs can increase use. In the first Trump administration, more frequent Medicaid eligibility checks led to losses in health coverage for more than a million poor children. Studies of student aid applications have shown that programs that help families fill out the forms boost college participation.
At the same time, there is no evidence that work requirements in food or health care programs actually cause more people to work — a consistent finding that the budget office folds into its estimates of the policy’s savings.
“Study after study after study, year after year after year have pointed out we really need to call them work reporting requirements, not work requirements,” said Heather Hahn, an associate vice president in the family and financial well-being division at the Urban Institute.
Complying with those reporting requirements can be especially hard for low-income workers who work multiple jobs with inconsistent hours. These workers are also less likely to have access to human resource departments that produce documents needed to comply — or the computers, scanners and printers necessary to duplicate and submit them.
Previous efforts to reduce that burden by linking eligibility in one program to others would dissolve under the Republican bill. For instance, children in families on SNAP are automatically enrolled in free and reduced-price lunches at school. But families who lose food assistance under the Republican bill may also automatically lose school meals for their children, unless they fill out new forms to sign up. The budget office estimated that child nutrition subsidies would fall for about 420,000 children as a result.
Struggles with paperwork are not unique to the poor. In a 2020 survey of 4,400 Americans conducted by Morning Consult for the Upshot, more than a quarter, across the income spectrum, said they had unopened mail in their house or had forgotten to pay a bill on time. These are the types of errors that could jeopardize assistance for poor Americans under the Republican bill.
“Anyone who has forgotten to cancel a free subscription before the subscription starts billing understands what it means to forget to do the thing,” said Adrianna McIntyre, an assistant professor of health policy at Harvard. She noted her internet service had been shut off a few times when she mistimed a bill payment.
The poor are also not alone in benefiting from government assistance. Americans who get health insurance through work receive substantial tax subsidies to help pay for it, without having to fill out forms every six months. Farmers who apply for aid from the Department of Agriculture don’t need to regularly prove they work, unlike recipients of food assistance, which is administered by the same agency.
“I would like to ask someone if they feel that additional paperwork for their employer insurance or Medicare would make them feel they are really earning the benefit,” said Jennifer Wagner, the director of Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities. “When it comes to low-income families, there is always this argument they should have to work harder to demonstrate their worthiness.”
Margot Sanger-Katz is a reporter covering health care policy and public health for the Upshot section of The Times.
Emily Badger writes about cities and urban policy for The Times from Washington. She’s particularly interested in housing, transportation and inequality — and how they’re all connected.
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