The Republican Assault on Medicaid Can Be Stopped

Their plans are horrific, but the politics are on Democrats' side.

Believe it or not, this man may not have your best interests at heart. (photo by Gage Skidmore)

Very soon, congressional Republicans will unveil their plan to take a chainsaw to Medicaid, one of the most worthwhile and beloved federal programs in existence. The assault is unlike anything they have attempted before: sweeping in its ambition, catastrophic in its likely effects, and abhorrent in its motives. This can and should be one of the most high-profile and consequential policy showdowns of the second Trump administration.

The Medicaid cuts are just one part of a gigantic budget bill that will emerge from the congressional abattoir dripping with the viscera of critical programs gutted or cancelled outright. But it deserves a special focus, especially since Medicaid now covers over 71 million Americans, with another 7 million kids on its subsidiary program CHIP. The stakes are incredibly high, and Democrats could not find a better issue on which to fight Trump and his allies.

But since it’s health policy, it’s complicated. Which is why I thought it might be useful to step back and focus on some core ideas that are most important for everyone — lay people, journalists, members of Congress — to keep at the top of mind as we begin to discuss the GOP attack on Medicaid, even if the policy details make your eyes glaze over.

1. The whole purpose of this effort is to fund a tax cut for the wealthy.

Yes, Republicans don’t like Medicaid and never have (more on that in a moment). But in this budget, they are looking to cut hundreds of billions of dollars from the program for one central reason: to pay for an extension of Trump’s 2017 tax cut, most of the benefits of which went to the wealthiest Americans. To pass that tax cut, they have to find over $4 trillion in cuts, and a big chunk of that is coming from Medicaid. It’s not complicated: Tax cuts for the rich, paid for by taking health coverage away from low-income people.

2. The purpose and effect of every one of the programmatic changes Republicans are considering is to reduce the number of enrollees, i.e. kick people off their health coverage.

Republicans are negotiating among themselves over a variety of means by which to cut the program. They are almost certain to impose “work requirements,” which are actually paperwork requirements, on beneficiaries. They considered (but seem to have set aside for now) a plan to slash the amount the federal government pays states for those who enrolled as part of the Affordable Care Act’s expansion of Medicaid, which would have triggered a number of state laws requiring massive rollbacks of enrollment. They are still mulling caps on spending for those expansion enrollees. They want to bar states from imposing certain taxes on providers; take that away, and cuts to enrollment are the likely consequence. They want to force enrollees to prove their eligibility more often; in other words, erecting more bureaucratic hurdles. They want to make people pay more for their coverage.

Whichever of these ideas survive, they are all about finding ways to kick people off the program. Work requirements, for instance, would probably result in about 5 million people losing coverage, despite the fact that almost everyone on Medicaid either already works or has a valid reason for not working, like a disability or responsibilities as a caregiver. The point is to kick people off, period.

3. Republicans want to punish people for having modest incomes.

Republicans would say that their most basic reason for looking to cut Medicaid is that they want government to be smaller. They do want that — but only when government is giving benefits to people they regard as morally unworthy. Their comments about Medicaid are riddled with moral condemnation, especially worries about “able-bodied” people getting health coverage, as though that were self-evidently repugnant. To listen to them, you’d think we were facing a national epidemic of laziness — but just among poor people — and the only solution is to punish as many people as possible by taking away their health coverage. If you haven’t heard them suggest that we should impose work requirements and drug testing on the mortgage interest deduction or the special tax treatment of capital gains, it’s because as far as they’re concerned, only poor people have to prove that they are morally worthy of receiving government benefits.

4. The effect of the changes they are proposing would be a sicker population, damaged state budgets, and a worse economy.

Republicans almost never talk about the practical consequences these cuts are going to have, because they’re all negative. This should surprise no one, because when you kick someone off their health coverage, the effect on their life can range from problematic to catastrophic; multiply that effect millions of times and society as a whole will suffer. Expanding Medicaid saved large numbers of lives, just as you’d predict it would. When people have coverage, they can go to the doctor when they’re sick, illnesses are treated, and they can remain productive and support their families. Medicaid expansion improved state budgets, reduced poverty, boosted economic growth, and stabilized hospital finances, especially rural hospitals.

All of which is to say that kicking millions of people off Medicaid won’t just hurt them and their families, it will have damaging effects that radiate outward to the entire country.

5. Whenever you hear Republicans say they’re going after “waste, fraud, and abuse” they’re lying.

There is Medicaid (and Medicare) fraud, but virtually none of it is from people getting on the program when they shouldn’t; most comes from providers submitting fraudulent claims (more on that here). Republicans almost never say what kind of “fraud” they’re concerned about, or how the proposals they’re offering would eliminate it. Just as Elon Musk’s destruction of the federal government isn’t really about “efficiency,” the GOP isn’t really going after waste, fraud, or abuse in Medicaid. Their problem is with the program itself.

This can be fought

It would be easy to despair, since Republicans seem determined to eviscerate Medicaid and they control Congress and the White House. But this is not over. There are multiple fractures within their party that can be exploited simply by focusing attention on this issue, which raises the political cost of doing what they want to do.

The first reason why is that cutting Medicaid is incredibly unpopular. Every poll that has been taken shows opposition on the order of two-thirds or more of the public. Trump’s own pollster has warned Republicans that cutting Medicaid to pay for tax cuts is rejected even by Trump voters. This isn’t an issue where the public is divided; people like Medicaid and don’t want to see it cut. That’s doubly true when the reason is to give a tax cut to the rich, which is also unpopular. “Republicans are going to do a thing you hate so they can do another thing you hate” is a pretty good message for Democrats.

Second, congressional Republicans are divided, with a significant group of vulnerable members from swing districts insisting that they don’t want big cuts, and hard-right conservatives insisting that there must be big cuts. Even some conservatives who want to position themselves as “populist” are pushing back:

“Twenty-one percent of my state is on Medicaid or CHIP,” Sen. Josh Hawley of Missouri told reporters Tuesday. “They’re on Medicaid because they can’t afford anything else. They’re not on Medicaid because they’re lazy. They’re on Medicaid because health insurance is so dadgum expensive.”

“I don’t understand the argument that says, ‘Yes, congratulations working folks, you voted for Donald Trump, and now we’re going to take away your access to health insurance,’” he continued. “It seems insane to me.”

I don’t have a lot of love for Josh Hawley, but it’s great to see a Republican making these arguments. This is a classic “wedge issue,” the kind that unites your party and divides the other party; Democrats need to keep pressing on that wedge.

Republicans have not resolved this conflict and come up with a bill that will satisfy everyone in their party — and they need everyone for the bill to pass. The House is 220-213 Republican at the moment, which means they can only lose three votes; the more swing district members can be convinced that voting to cut Medicaid will end their careers, the more reluctant they’ll be.

Then there’s President Trump, who is clearly wary of Medicaid cuts. “They’re not cutting it,” he said in a recent interview. “They’re looking at fraud, waste and abuse.” He has also said repeatedly that Medicaid “isn’t going to be touched.” The clearer the political cost becomes, the more likely it is that he will pull the plug.

Which means that we all have power to stop this. That doesn’t mean there’s a happy ending waiting for us in which the program survives untouched; there will almost certainly be some damage one way or another. But Medicaid can be saved, if everyone makes enough noise.

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