When Congress passed President Trump’s signature domestic policy bill last month, Republicans voted to take health care coverage away from about 10 million people. In the past, Republicans have typically shied away from promoting plans to end health benefits for millions. But in this case, they openly boasted about part of it.
About half of the 10 million will lose coverage because of a new requirement that people who enroll in Medicaid prove that they are working, looking for work or unable to work. The new policy will cut Medicaid spending by $325 billion over the next decade, funds that will be used to finance President Trump’s tax cuts for the wealthy.
“They are choosing not to work when they can,” House Speaker Mike Johnson told CNN earlier this year, describing the people who would lose coverage. “That is called fraud; they are cheating the system.”
John Thune, the Senate majority leader, said in June that “Democrat senators here in Washington are melting down because Republicans are daring to focus limited Medicaid dollars on American citizens and those most in need.” He described work requirements as a “common-sense reform.”
The idea of requiring Medicaid enrollees to work barely registered eight years ago, the last time Republicans debated deep health care cuts as part of their effort to repeal Obamacare. They failed to pass a law that time.
This time they were successful. That’s in part because Republicans have put more stock in an idea that has long been a part of the American conversation about health insurance: that it is a benefit one earns by working. Work requirements have overwhelming support among Republicans, and polls have found that about half of Democrats back the idea, too.
Democrats have warned that some people who do work will lose Medicaid because they can’t file the right paperwork. Republicans concede that this is possible, but that it isn’t nearly as harmful as liberals think.
This is the second key idea that helped move the coverage cuts forward: the belief that health insurance coverage isn’t actually an essential benefit. Research connecting health insurance to better health outcomes is surprisingly mixed, with multiple, large-scale studies either not finding a relationship or showing one only among especially sick patients. If this is true, it’s because the United States’ large uninsured population has forced the creation of a vast, ad hoc safety net that fills the gaps in a patchwork system.
Both of these ideas are inextricable from the peculiarities in the American health care system.
Working for Your Health Care
In the years following World War II, most of the United States’ peer countries were creating universal health coverage. Each put its own spin on the idea. Britain made doctors government employees when it built its National Health System in 1948. Canada’s coverage scheme relied on public insurance that paid private doctors for care. Australia came up with a two-tier system: basic public insurance for everybody, with the option to buy a private plan for more generous benefits.
The United States took a completely different path: It tied insurance to employment.
This had begun in the 1940s, when American companies facing labor shortages began courting workers by offering them health benefits. Employers were under wartime wage controls but insurance coverage didn’t count, making it an attractive way to provide additional compensation. In 1954, the Internal Revenue Service gave employer-sponsored insurance an even bigger boost when it made health benefits tax-exempt.
The number of Americans who got insurance at work swelled to 17 percent in 1960 from 9 percent in 1940. That number steadily grew to just under half of the population today.
Future expansions of health care focused on filling the gaps for those who weren’t employed. Democrats’ efforts to push for universal coverage were unsuccessful, with Republicans arguing for a smaller government role in health care (often with the powerful doctor lobby, the American Medical Association, on their side).
After years of debate, Medicare and Medicaid started in 1966. Medicare was a straightforward program that covered all adults over 65. It was akin to a miniature Canadian system — just for seniors. Medicaid was more complicated. It gave the coverage only to those already receiving cash assistance because they had conditions excluding them from employment. At the time, this included the blind, people with disabilities and single women with children.
The list of Medicaid-qualifying conditions grew over the decades, expanding to cover pregnant women in 1984 and more children in 1997. But the assumption remained that Medicaid went only to those who were vulnerable in some way beyond being poor.
Democrats tried to break that link with Obamacare. The law, passed in 2010, expanded Medicaid to anyone who earned less than 133 percent of the federal poverty line. They refashioned Medicaid to look more like Medicare, a program that covers everybody who meets a single condition.
Even so, the concept of linking health insurance to employment remained a potent one for Americans. In my own reporting, I’ve often spoken to people with private insurance who were resentful that others who did not work suddenly had free health coverage. They would point out that Medicaid coverage seemed better than what they got at work. And those people weren’t necessarily wrong: Medicaid only rarely charges deductibles or co-payments, whereas the average employer plan now has a nearly $2,000 deductible before it kicks in.
A few years after Obamacare passed, several Republican states began proposing adding a work requirement to the program. Most were blocked by the Biden administration or the courts. Still, they provided a road map for Congress to use when writing a national version.
Two states, Arkansas and Georgia, did manage to implement the program, although Arkansas’s ended in 2019.
“It gains traction and momentum because it reflects common sense,” said Asa Hutchinson, who implemented a Medicaid work requirement in Arkansas when he was governor. “Somebody who is able-boded and receiving a public benefit, they ought to have a responsibility.”
A National Patchwork
In December 2024, two months after Mr. Trump’s re-election, the influential Paragon Institute published a paper titled “What Matters for Health: Insurance Is Less Important Than You Think.”
Since its founding in 2021, Paragon has quickly become a leading authority in conservative health policy. Many of the think tank’s members are veterans of the first Trump administration. And as Republicans prepared to take full control of Washington, Paragon was elevating the idea that people won’t face much harm if they lose medical coverage.
Their argument was rooted in research. Multiple, large-scale studies have looked at the relationship between insurance coverage and health outcomes — and sometimes found that it’s not as obvious as you might expect.
The first randomized study on the topic, conducted in the 1970s, found that making health care more expensive did not lead to bad health outcomes for patients. Another high-profile study from M.I.T. and Harvard economists, published in 2013, looked at what happened after Oregon held a lottery for Medicaid coverage (the state was doing a limited expansion and did not have the money to cover everyone who wanted to sign up). It found some improvements in mental and financial health but, again, did not show improved physical outcomes.
“For most people, insurance coverage has little or no impact on objective measures of health,” concluded Joel Zinberg and Liam Sigaud, the authors of the Paragon study.
Many health economists would dispute that claim. Newer research that uses bigger data sets has started to find that insurance coverage, and Medicaid in particular, does lower death rates. The connection is strongest when researchers look at older, sicker populations.
There is also the financial and mental strain of lacking coverage, which can affect a person’s well-being but wouldn’t turn up in a study that strictly measured physical health outcomes. In my 15 years covering America’s health system, I’ve talked to more uninsured patients than I can count who are too scared to go to the doctor because they fear a large bill on the other end.
But the ideas that the Paragon paper articulated, which have also come up in writing from experts at the Cato Institute and the Heritage Foundation, have increasingly found a receptive audience in Washington.
Mr. Sigaud, a co-author of the Paragon paper, took multiple meetings with congressional Republicans and their staff after publishing his findings.
“It’s no longer taken as a given that the health benefits are very substantial,” he said of those conversations. “There’s less of a reluctance to trade off potential coverage losses, at least in Medicaid.”
The paper’s other author, Mr. Zinberg, now works for the White House advising the Trump administration on health policy.
If their ideas are correct, it is largely because of how the American health care system has developed since Medicare and Medicaid became law and it became clear that the United States would not provide health coverage to all Americans.
In 1965, the federal government began funding a few “neighborhood health clinics” in poor areas of the country. The number grew to over 100 by the 1970s. The government has continued to plow more funds into the program. There are now about 15,000 federally funded clinics that help serve the poor and uninsured. These centers are required to offer a sliding payment scale based on the patient’s ability to pay.
The people who lose health insurance “can walk into those facilities and receive totally free primary care and some secondary care, absolutely for free,” said Robert Rector, a research fellow at the Heritage Foundation.
In the 1980s, legislators were confronted with another problem: emergency rooms refusing to see patients who did not have the means to pay. This led to the Emergency Medical Treatment and Labor Act, which requires emergency rooms to provide “life-stabilizing” treatment to everyone, even the uninsured. The wait in the emergency department may be long, conservatives contend, but the patient will be seen and the emergency will be treated.
This is the Whac-a-Mole version of health care policy — an attempt to ensure that even in a system where insurance and care are tied to employment, our society protects the most vulnerable. The outcomes are decidedly mixed. Uninsured Americans may be scraping together the care they need from free clinics and emergency rooms but they may be doing so at great personal cost, arranging child care for a long wait or having their paycheck garnished when they can’t pay the medical bill.
With some 10 million people expected to lose their access to Medicaid in the decade after the domestic policy bill goes into effect in 2027, more patches may soon be needed in the system.
A Political Minefield
The story of health insurance in the United States has generally been one of expansion, albeit in fits and starts. From private insurance to Medicare and Medicaid to Obamacare, the country has slowly increased the number of people who get health insurance.
The recent policy bill represents a break from that trajectory. It is a remarkably different outcome from what happened the last time Republicans tried to reduce coverage.
That was in 2017, when Mr. Trump had come into office promising to repeal and replace President Barack Obama’s signature health care law. Congressional Republicans made repeal their first legislative priority.
Obamacare was still experiencing growing pains, and Republicans roundly opposed it. But it was also providing health insurance to over 25 million people, including many who had voted for Mr. Trump.
Each replacement law they produced left millions fewer covered. Too many Republican legislators decided they could not survive such a vote.
It’s possible they eventually decide they cannot handle the health care cuts this time, either. The Medicaid work requirements in the policy bill do not take effect until 2027 and, at the last minute, the Senate added a waiver provision that could push the policy back until 2029.
Days after voting in favor of passing the megabill, Senator Josh Hawley, Republican of Missouri, introduced legislation to roll back some of the Medicaid cuts it enacted.
“Now is the time,” he said in a statement about the legislation, “to prevent any future cuts to Medicaid from going into effect.” He still supports Medicaid work requirements.
Sarah Kliff is an investigative health care reporter for The Times.
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