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REPUBLICANS WANT TO GUT MEDICAID. THEY MIGHT REGRET IT.  
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Michael Kinnucan
February 28, 2025
New York Times
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_ Some red-state governors would very likely push back against cuts
that might force them to make an unpopular choice between cutting
their Medicaid programs or raising taxes. _

, Illustration by The New York Times. Photograph by Getty Images.

 

While President Trump has been busy with his executive branch rampage,
congressional Republicans have been pursuing a plan to extend and
enlarge Mr. Trump’s 2017 tax cuts, which favor the richest
Americans.

But the math is stubborn, particularly since Mr. Trump has repeatedly
pledged to avoid cuts to Medicare and Social Security. And that has
put Medicaid, the federally subsidized program run at the state level
that provides health insurance or long-term care coverage to more than
70 million Americans, in the G.O.P.’s sights — even though Mr.
Trump said
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this month that Medicaid, too, wouldn’t be “touched.”

On Tuesday, House Republicans took the first step
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toward Medicaid cuts by passing a budget resolution that could mean up
to $880 billion in cuts to Medicaid over 10 years. Now they have to
actually identify specific cuts to the program — deciding which
patients, providers and state governments will lose, and how much.

Republicans are fooling themselves if they think it will be easy.
Gutting Medicaid means attacking a program backed by a wide range of
organizations — from the AARP to the American Hospital Association
— that also enjoys broad public support. Even longtime Trump ally
Steve Bannon recently warned
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“A lot of MAGA’s on Medicaid,” adding, “just can’t take a
meat ax to it, although I would love to.”

The federal government spends around $600 billion a year on Medicaid.
It reimburses states for at least 50 percent
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of program costs. (Rich states like New York and California typically
get 50 percent, while some poor states, like West Virginia and
Mississippi, get over 70 percent.)

Significant cuts to this funding would send fiscal shock waves through
state governments across the country as billions of dollars in federal
funding stopped flowing, forcing states to decide where and how to cut
their Medicaid programs — whether to eliminate coverage for some
beneficiaries, reduce payments to physicians, deny home care to some
seniors or raise state taxes to make up the difference.

This isn’t the first time Medicaid has faced attacks. The program
was created, alongside Medicare, in 1965, and by the 1970s, some
observers were already predicting its demise. In the early years, the
program was sometimes stigmatized as “welfare medicine
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Many liberals saw it as a poor substitute for universal health care;
many conservatives didn’t like the program’s rising costs. In both
the 1980s and the 1990s, Republicans made attempts
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at turning Medicaid into a block grant program — giving states a
fixed amount of money, putting the burden of increased costs on them
and capping federal expenditures.

Medicaid not only survived these efforts, it has expanded, including
to more children through the closely related Children’s Health
Insurance Program, known as CHIP. Medicaid expansion was at the heart
of the Affordable Care Act — Obamacare — helping cut the
percentage of America’s uninsured people roughly in half, to around
8 percent
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in 2023.

Once considered a poor people’s program, Medicaid has proved itself
a political juggernaut. Why? Start with the money. The Medicaid
program spends about $900 billion
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a year in state and federal funds, paying for close to one-fifth
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care expenditures in the United States. The program is the primary
payer for almost two-thirds
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of nursing home residents and funds just over 60 percent of long-term
care.

Hospitals have an obligation in many instances to provide care even
when patients can’t pay. Significant Medicaid cuts would almost
certainly leave hospitals to provide more uncompensated care. Many
medical facilities, particularly in low-income and rural communities,
could be at greater risk of closing. That’s among the reasons the
hospital industry has supported Medicaid expansion
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and opposed cuts
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the state and federal levels.

Hospitals are politically influential. According to OpenSecrets, in
2023 and 2024, the hospital and nursing home industries accounted for
$62 million
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political contributions. And hospitals are major employers: Indiana
University Health has about 36,000 employees and Prisma Health in
South Carolina has 29,000 employees.

If they vote to cut Medicaid, Republicans probably won’t just face
opposition from patient advocates and liberal do-gooders. They’ll
very likely hear from the board members and executives of major
employers in their districts.

They’re also very likely to face opposition from another
constituency: older voters and voters who have family members with
disabilities. Medicare generally doesn’t pay for nursing homes and
home care for elderly and disabled Americans; Medicaid does. Medicaid
also helps pay Medicare premiums and co-pays for low-income seniors
through Medicare Savings Programs. And it funds a substantial portion
of supportive services for the intellectually and developmentally
disabled.

Low-income seniors may not sound like a powerful constituency, but
many people who benefit from Medicaid long-term care coverage don’t
start out_ _as_ _low-income. Nursing home care can easily cost
$100,000 a year; many middle-class families who start out paying out
of pocket will find that their loved ones become eligible for Medicaid
in short order. That means there is a broad middle-class constituency,
including Republican voters, that relies on Medicaid-funded long-term
care.

Medicaid is crucial to state budgets_ — _including in red states. On
average, when federal funds are included, Medicaid represented 28.8
percent
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of states’ budgets in 2022. Even a relatively limited federal
cutback could present many states with fiscal crises. Some red-state
governors would very likely push back against cuts that might force
them to make an unpopular choice between cutting their Medicaid
programs or raising taxes.

Blue-state Republicans might balk as well: A Medicaid cut might be a
tough sell for the seven Republicans from New York and nine from
California helping to prop up Republicans’ three-vote House
majority.

Republicans might find all these sources of opposition — provider
lobbies, Medicaid beneficiaries, Republican governors, blue-state
Republicans — more manageable if the public supported their larger
goal of shrinking Medicaid. But far from supporting Medicaid cuts,
voters — even those in deep-red states like Idaho, Missouri and
Oklahoma — have voted for Medicaid expansion_ _by ballot initiative.
A 2024 KFF poll found
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that 71 percent of adults think that Medicaid should largely continue
as it is today, and 66 percent of adults in (overwhelmingly
Republican) non-expansion states support expansion. A Pew Research
Center poll recently found
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that 65 percent of Americans think that “it is the federal
government’s responsibility to make sure all Americans have health
care coverage.”

That’s among the reasons Republicans’ last major push to cut
Medicaid spending, in 2017, fell apart. In 2016, Mr. Trump and
Republicans ran on rolling back the A.C.A., but the bottom fell out of
their effort when the Congressional Budget Office estimated
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that the Republican plan would increase the number of people without
health insurance by more than 20 million in a decade. The effort to
repeal the A.C.A. stumbled on for several more weeks before Senator
John McCain famously put it out of its misery
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There’s little evidence the public’s views on this issue have
changed since. Republicans hoping to slash Medicaid for the sake of
tax cuts do so at their peril.

Michael Kinnucan is the health policy director at the Fiscal Policy
Institute.

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