Under President Joe Biden, enrollment in Medicaid hit a record high and the uninsured rate reached a record low.
Donald Trump鈥檚 return to the White House 鈥� along with a GOP-controlled Senate and House of Representatives 鈥� is expected to change that.
Republicans in Washington say they plan to use funding cuts and regulatory changes to dramatically shrink Medicaid, the nearly $900-billion-a-year government health insurance program that, along with the related Children鈥檚 Health Insurance Program, s mostly low-income or disabled Americans.
The proposals include rolling back the Affordable Care Act鈥檚 expansion of Medicaid, which over the last 11 years added about 20 million low-income adults to its rolls. Trump has said he wants to drastically cut government spending, which may be necessary for Republicans to extend 2017 tax cuts that expire at the end of this year.
Trump made little mention of Medicaid during the 2024 campaign. The first Trump administration approved work requirements in several states, though only Arkansas implemented theirs before a federal judge said it violated the law. The first Trump administration also sought to block-grant funding to states.
House Budget Committee Chair Jodey Arrington (R-Texas) told 杨贵妃传媒視頻 Health News that Medicaid and other federal entitlement programs need major changes to help cut the federal debt. 鈥淲ithout them, we will watch this country sadly enter into fiscal collapse.鈥�
Rep. Chip Roy (R-Texas), a member of the Budget Committee, said Congress needs to explore cutting federal spending on Medicaid.
鈥淵ou need wholesale reform on the health care front, which can include undoing a lot of the damage being done by the ACA and Obamacare,鈥� Roy said. 鈥淔rankly, we could end up providing better service if we do it the right way.鈥�
Advocates for poor people fear GOP funding cuts will leave more Americans without insurance, making it harder for them to get care.
鈥淢edicaid is an obvious target for huge cuts,鈥� said Joan Alker, executive director of Georgetown University鈥檚 Center for Children and Families. 鈥淎n existential fight about Medicaid鈥檚 future likely lies ahead.鈥�
Medicaid, which turns 60 in July, is nearing the end of a disruptive period, after covid pandemic-era coverage protections expired in 2023 and all enrollees had to prove they still qualified. More than 25 million people lost coverage over the 18 months after the 鈥渦nwinding鈥� began, though it has not notably increased the number of people without insurance, according to the latest census data.
The could pale in comparison to what happens in the next four years, said Matt Salo, former executive director and founder of the National Association of Medicaid Directors. 鈥淲hat we are going to see is an even bigger seismic shift in who Medicaid covers and how it operates,鈥� he said.
But Salo said any efforts to shrink the program will face pushback.
鈥淎 lot of powerful entities 鈥� state governments, managed-care organizations, long-term care providers, and everyone under the sun who wants to do well by doing good 鈥� wants to see Medicaid work efficiently and be adequately funded,鈥� he said. 鈥淎nd they will be highly motivated to push back on something they see as draconian cuts, because it could affect their business model.鈥�
The GOP is looking at several tactics to reduce the size of Medicaid:
- Shifting to block grants. Switching to annual block grants could lower federal funding for states to operate the program while giving states more discretion over how to spend the money. Currently, the government matches a certain percentage of state spending each year with no cap. Republican presidents since Ronald Reagan have sought to block-grant Medicaid with no success. Arrington said he favors ending the open-ended federal funding to states and replacing it with a set annual amount based on how many people each state has in the program.
- Cutting ACA Medicaid funding. The ACA provided financing to cover, through Medicaid, Americans with incomes up to 138% of the federal poverty level, or $20,783 for an individual last year. The federal government pays 90% of the cost for adults covered through the law鈥檚 Medicaid expansion, which 40 states and Washington, D.C., have adopted. The GOP may try to lower that funding to the same match rate the feds pay states for everyone else in the program, which averages about 60%. 鈥淲e should absolutely note that we are subsidizing the healthy, able-bodied Medicaid expansion population at a higher rate than we do the poorest and sickest among us, which was the original intent of the program,鈥� Arrington said. 鈥淭hat鈥檚 not right.鈥�
- Lowering federal matching funds. Since Medicaid began, the federal match rate has been based on the relative wealth of a state鈥檚 population, with poorer states receiving a higher rate and no state receiving less than a 50% match. Ten states get the base rate 鈥� all but two are Democratic-run states, including New York and California. The GOP may seek to cut the base rate to 40% or less.
- Adding work requirements. During the first Trump term, federal courts ruled that Medicaid law doesn鈥檛 allow coverage to be conditioned on enrollees鈥� working or seeking jobs. But the GOP may try again. 鈥淚f we can get strict work requirements on able-bodied adults, that can be a huge cost savings by itself,鈥� Rep. Tom McClintock (R-Calif.) told 杨贵妃传媒視頻 Health News. Because most Medicaid enrollees already work, go to school, or serve as caregivers, critics say such a requirement would simply add red tape to obtaining coverage, with little impact on employment.
- Placing enrollment hurdles. About 10 states offer some populations what鈥檚 called continuous eligibility, whereby people stay enrolled for years without having to renew their coverage. That policy鈥檚 been shown to prevent enrollees from falling out of the program for short periods because of hardships or paperwork problems, which can lead to surprise medical bills and debt. The Trump administration could seek to repeal waivers that allow states to grant multiyear continuous eligibility, which would require people in those states to reapply for coverage annually.
If the GOP鈥檚 plans to shrink Medicaid are realized, Democrats and health experts say, low-income people forced to buy private insurance would face challenges paying monthly premiums and the large copayments and deductibles common to commercial plans that typically don鈥檛 exist in Medicaid.
The Paragon Health Institute, a leading conservative think tank run by former Trump adviser Brian Blase, has saying the billions in extra money states took to expand Medicaid under the ACA has been a boon to private insurers that manage the program and relatively wealthier people it says shouldn鈥檛 be enrolled.
Josh Archambault, a senior fellow with the conservative Cicero Institute, said he hopes the Trump administration holds states accountable for overpaying providers and enrolling people in Medicaid who are not eligible. Conservatives have cited CMS reports saying states improperly pay Medicaid providers billions of dollars a year, though the federal government notes that is mostly due to lack of documentation.
He said the GOP will look to scale back Medicaid to its 鈥渢raditional鈥� populations of children, pregnant women, and people with disabilities. 鈥淲e need to rebalance the program that most people think is underperforming,鈥� he said. Most Americans, including large majorities of both Republicans and Democrats, view the program favorably, .