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See update at bottom for the purest expression of emerging Republican policy and messaging in the drive to cut Medicaid— from Brian Blase, Republicans’ chief ideologist on this front.
What’s wrong with this Democratic Party broadside against Republican plans to cut federal Medicaid funding?
The problem: In their likeliest path to cutting Medicaid, Republicans may well leave coverage for kids and seniors more or less untouched. They’re gunning for a different group of enrollees: 20 million low-income adults rendered eligible by the ACA Medicaid expansion.
I fear that in their language defending Medicaid from pending deep Republican spending cuts, some Democrats and advocates may be fighting the last war - -and walking into a trap.
In their ACA “repeal and replace” bills in 2017, Republicans would have defunded the ACA Medicaid expansion, which at that time insured about 15 million low-income adults, and also imposed “per capita caps” or block-granting on Medicaid. Those broader-based cuts would have slow-strangled Medicaid funding over time, forcing states to cut back on benefits and enrollment across a broad range of enrollment categories. The most effective lobbyists against the cuts were groups representing the most obviously vulnerable individuals — the disabled, and medically fragile children.
This time around, the budget resolution that passed the House in late February, will all but one Republican and no Democrats voting in favor, sets a target of $880 billion over ten years in federal spending overseen by the Energy and Commerce Committee — the vast majority of which would have to come out of Medicaid. At the same time, while blessing that resolution, Trump said he wanted Congress to “cherish” Medicaid and not “touch” it. To square that circle, Republican leadership appears to have homed in on repealing the enhanced federal contribution for the ACA Medicaid expansion population, a cut worth $651 billion over ten years, according to CBO. Speaker Mike Johnson, however, has taken per capita caps or block granting off the table.
To defend effectively repealing the ACA Medicaid expansion (as no state will be able to afford maintaining without the 90% federal contribution), Republicans are defining enrollment of low-income adults who don’t meet federal disability criteria as “waste, fraud, and abuse.” They are vowing to protect Medicaid for groups they define as “deserving” — children, the disabled, and nursing home enrollees.
As I noted in a Star-Ledger op-ed and followup post here, you can tell which Republican reps are on board with ending the ACA expansion by noting whom they include or exclude when enumerating the groups whose Medicaid deserves protection. If they omit “low-income families,” like Rep. Tom Kean Jr. (NJ-7), they are on board. If they include that phrasing (as illustrated in this post), they would probably prefer not to defund the expansion.
Kean’s statement of “support” for Medicaid enrollees — minus the expansion population — neatly captures the emerging Republican doublespeak:
I support strong Social Security, Medicare, and Medicaid programs for those who depend on them. Children, seniors, and those who are disabled rely on these crucial programs…I do not support these programs being riddled with waste, fraud, and abuse — that is a direct threat to their actual missions.
Children, the disabled, and the elderly in need of long-term care are more obviously sympathetic groups than adults with income low enough to qualify them for Medicaid by ACA expansion criteria (income under 138% of the Federal Poverty Level, about $21,600 for an individual this year). And again, the spectacle of the disabled in wheelchairs being carted by police out of the Capitol rotunda in a 2017 protest against the pending ACA repeal bills was visceral, and perhaps decisive in defeating the bills.
Accordingly, Democrats and advocates often lead with those groups when decrying the pending cuts. The Medicaid expansion population is sometimes excluded from their protestations, as surely as it is from Republicans’ statements of protection. Here, for example, is Amy Klobuchar on threads:
People need to understand what this budget the Republicans have proposed for the long term would mean in their everyday lives..72 million people in America are on Medicaid. When you look at our seniors in Minnesota alone it’s over a million people, and one out of five rural Minnesotans is on Medicaid. That is what we’re dealing with when we talk about how important Medicaid is. It is important for any family who knows that they have a senior who is going to go into assisted living or is already in assisted living.
To which Republicans will respond, if/when they do unveil bills that gut the ACA expansion, “these cuts do not affect seniors in assisted living at all.” Ditto for children and those enrolled in the Aged, Blind or Disabled (ABD) category.
As for the expansion population, this is the Freedom Caucus response, emerging as the party line:
Medicaid was intended to assist vulnerable populations like the disabled, pregnant women, children and people in poverty. Today, able-bodied, working-capable adults are on course to become the largest subgroup on Medicaid.
And, according to conservative Republicans, that’s bad! “Able-bodied” adults don’t deserve free health coverage! It discourages work! This is where the argument should be, and probably will be as Republican plans harden.
Another Medicaid cut that Republicans will almost certainly attempt is also aimed at the ACA expansion enrollment group: imposing work requirements on enrollees who are not disabled (valued at $100 billion/ten years by CBO). Work requirements poll well, as Americans don’t generally realize that most Medicaid enrollees aged 19-64 who don’t qualify for SSI do work. According to the Kaiser Family Foundation, 64% of such enrollees work, and another 28% are caregivers, students, or not working due to illness or disability, . The administrative burden imposed on enrollees by the requirement to report working hours, or attempts to find work, or reasons why they cannot work, drive many eligible people off the rolls, as an abortive trial in Arkansas — cut off by court order — showed in 2018.
Extending Medicaid to low-income adults has cut the uninsured rate by about 40% nationally - and by about 50% in the nation’s poorest states, which are without exception red states. The ACA Medicaid expansion is good for state economies, vital to rural and safety-net hospitals, and good for the financial, mental, and physical health of beneficiaries. It is not hard to defend, and that’s where Democrats’ rhetorical focus should be.
I shouldn’t overstate this problem of rhetoric and focus. The bulletin cited at top contains an array of quotes and facts, some which focus on the ACA expansion. Today Frank Pallone excoriated Republican attempts to cut the ACA expansion. Further, Republicans could change course in their approach to cutting Medicaid, especially if they scale back their ambitions and focus on things like limiting state provider taxes, which would not focus particularly on the ACA expansion group. But I do keep seeing summaries of those under threat that lead with or focus exclusively on groups that Republicans are likely to claim they’re protecting.
UPDATE, 3/19/25: Brian Blase, founder/president of the Paragon Health Institute and the chief ideologist behind Republican plans to double the uninsurance rate, is touting a push-poll that finds support for gutting the ACA Medicaid expansion when framed in Republican terms. This is the argument Democrats need to counter:
One of the most perverse features of federal Medicaid policy is that Washington reimburses a much higher percentage of state spending on able-bodied, working-age adults than it reimburses for children, pregnant women, seniors, and the disabled. Ending that disparity is the right public policy and popular with the American people. Nearly two-thirds of Americans support “Congress lowering the percentage that the federal government pays states for Medicaid costs for able-bodied, working-age adults to the same level it pays for pregnant women, children, and those with disabilities.” Health policy can be complex, but when framed in clear terms, voters overwhelmingly side with taxpayers financially supporting those who are less able to privately finance their medical services.
In this perverted view, insuring low-income adults is the “waste, fraud and abuse” that Republicans pledge to cut:
Across party lines, Americans overwhelmingly support policies that prioritize children, pregnant women, seniors, and the disabled and that root out waste, fraud, and abuse. They want fiscal responsibility, not policies that strain resources and make it harder for the truly needy to access care.
N.B. The headline for this post originally typoed “costs” for “cuts” — sorry about that. Corrected.
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