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Under President Joe Biden, enrollment in Medicaid hit a record high and the uninsured rate reached a record low.
Donald Trump’s return to the White House — along with a GOP-controlled Senate and House of Representatives — 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’s Health Insurance Program, serves about 79 million mostly low-income or disabled Americans.
The proposals include rolling back the Affordable Care Act’s 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 KFF Health News that Medicaid and other federal entitlement programs need major changes to help cut the federal debt. “Without them, we will watch this country sadly enter into fiscal collapse.”
Rep. Chip Roy (R-Texas), a member of the Budget Committee, said Congress needs to explore cutting federal spending on Medicaid.
“You need wholesale reform on the health care front, which can include undoing a lot of the damage being done by the ACA and Obamacare,” Roy said. “Frankly, we could end up providing better service if we do it the right way.”
Advocates for poor people fear GOP funding cuts will leave more Americans without insurance, making it harder for them to get care.
“Medicaid is an obvious target for huge cuts,” said Joan Alker, executive director of Georgetown University’s Center for Children and Families. “An existential fight about Medicaid’s future likely lies ahead.”
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 “unwinding” began, though it has not notably increased the number of people without insurance, according to the latest census data.
The unwinding’s disruptions 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. “What we are going to see is an even bigger seismic shift in who Medicaid covers and how it operates,” he said.
But Salo said any efforts to shrink the program will face pushback.
“A lot of powerful entities — state governments, managed-care organizations, long-term care providers, and everyone under the sun who wants to do well by doing good — wants to see Medicaid work efficiently and be adequately funded,” he said. “And they will be highly motivated to push back on something they see as draconian cuts, because it could affect their business model.”
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’s 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%. “We 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,” Arrington said. “That’s not right.”
- Lowering federal matching funds. Since Medicaid began, the federal match rate has been based on the relative wealth of a state’s population, with poorer states receiving a higher rate and no state receiving less than a 50% match. Ten states get the base rate — 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’t allow coverage to be conditioned on enrollees’ working or seeking jobs. But the GOP may try again. “If we can get strict work requirements on able-bodied adults, that can be a huge cost savings by itself,” Rep. Tom McClintock (R-Calif.) told KFF 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’s called continuous eligibility, whereby people stay enrolled for years without having to renew their coverage. That policy’s 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’s 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’t exist in Medicaid.
The Paragon Health Institute, a leading conservative think tank run by former Trump adviser Brian Blase, has issued reports 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’t 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 “traditional” populations of children, pregnant women, and people with disabilities. “We need to rebalance the program that most people think is underperforming,” he said. Most Americans, including large majorities of both Republicans and Democrats, view the program favorably, according to polls.