The Real MediScam
Republicans are lying about what’s driving their Medicaid cuts
Republicans have known for some time that they have a problem. The Trump tax cuts for the wealthy, passed in 2017, are set to expire at the end of this year. If they don’t renew them, they will have to answer to their big donors. But if they do renew them, as they almost certainly will, it will blow a massive hole in the budget, requiring a hefty debt ceiling raise.
That has angered fiscal hawks on the GOP right, who have demanded $2 trillion in spending cuts to help offset the deficit. That number has come down by around half recently, but it still means deep cuts to government programs.
The only place where Republicans can find this kind of money is in earned benefits and medical care. So they sent their budget to the House Committee on Energy and Commerce, which oversees Medicare and Medicaid, to find hundreds of billions in cuts.
Yesterday, the GOP announced where these cuts would come from. And to no one’s surprise, the big target is Medicaid, which provides health benefits for the poorest Americans. After making empty promises that they wouldn’t touch Medicaid, they’ve come at it with a sledgehammer, looking to knock some $715 billion out of Medicaid costs.
Let’s look at what that means in real terms, how the GOP is seeking to justify such deep cuts, and why its talking points about “work requirements” and “waste, fraud, and abuse” are a smokescreen for what Republicans really want.
By the numbers
Thank goodness we still have a nonpartisan Congressional Budget Office (CBO) that can issue fact-based projections about the true impact of policy proposals. After the planned Medicaid cuts were announced, CBO issued its findings, with estimated impacts summarized in a memo addressing concerns by Democrats on the Energy and Commerce Committee.
There are three principal GOP attacks on existing Medicaid funding. Some of these are arcane accounting processes while others are more straightforward stiffening of eligibility requirements. There is some overlap among these attacks:
Expiration of “expanded premium tax credits” (4.2 million more uninsured by 2034);
The “2025 Marketplace Integrity and Affordability” Rule (1.8 million more uninsured by 2034); and
Energy and Commerce’s reconciliation recommendations, including work and other eligibility requirements (7.7 million more uninsured by 2034).
We should focus most on the bottom line number: “In total, CBO estimates that these three actions would increase the number of people without health insurance by at least 13.7 million in 2034.”
Let’s say it plainly. 13.7 million is a huge number. And it draws completely from among the working poor. Many if not most live in states that are simply unable to make up the funding gap that the federal government would create by these moves.
The likely loss of insurance for 13.7 million Americans is not surprising when you have stripped out $715 billion from Medicaid funding. That money has to come from somewhere. The GOP is trying to pretend this won’t have massive, and very often fatal, consequences. It acts like this won’t up-end the lives of the most vulnerable among us. But the numbers don’t lie, and this is the nightmare that these cuts would create.
It’s important to emphasize that these cuts do not actually have to happen. This is a policy choice by Republicans to prioritize tax cuts for the wealthy over basic healthcare for the poor. Democrats don’t wish to cut the safety net out from under the working poor just so millionaires and billionaires can keep more of their money.
The two parties are not the same.
Bogus justifications
We are about to hear Republicans tell the public that up is down, that cuts are not cuts, and that the only people who will lose health care coverage are people who should have to work for their benefits.
Speaker Johnson acts like this is about giving people on Medicaid a gift, saying at the time the budget outline first passed, "You return the dignity of work to young men who need to be out working instead of playing video games all day."
As I’ll discuss below, this is not about the “dignity of work.” Those who will lose their health insurance aren’t young men on the couch playing video games. The suggestion is both anti-factual and frankly offensive.
Trump also promised not to touch Medicaid. But when asked if he would veto a bill that slashed it, Trump responded, “I would if they were cutting it but they’re not cutting it. They’re looking at fraud, waste, and abuse.”
This is a lie. While there is certainly some “waste, fraud, and abuse” in every government program, the bulk of the cuts on the table will be achieved by pushing currently eligible people off the Medicaid rolls.
“Work requirements” are really just new administrative obstacles
To hear Speaker Johnson tell it, the cost savings in Medicaid will come from forcing people back into the workforce as though able-bodied Medicaid recipients are all gaming the system by receiving benefits while sitting on the couch and not working.
This is a deliberate misrepresentation of what would actually happen.
As KFF (formerly known as the Kaiser Family Foundation), a health policy nonprofit, noted, most Medicaid-eligible adults under 65 are already working full or part-time, even without any kind of “work requirement” eligibility test.
Republicans know this, but they are actually pushing work requirements to make it harder for people who are already working to obtain benefits.
This has a parallel in their voter suppression playbook. Republicans impose new voter ID requirements knowing that this will make it harder for young people, minorities, and the disabled to cast ballots because these voters often don’t have driver’s licenses or passports. The GOP claims the new requirements are there to reduce fraud, even though there’s no evidence of widespread fraud. But its true intention is to suppress the number of these voters.
They’re now trying the same thing with Medicaid. By imposing new “work requirements” that force people to prove they have been working before receiving basic health insurance, some percent of the population—particularly in minority communities—will inevitably miss deadlines, fail to produce paperwork, or won’t be able to travel long distances or take time off from work just to prove eligibility.
See how that works?
Work eligibility requirements are nothing more than administrative hurdles that push already eligible people off Medicaid.
We know this because we’ve seen it happen
During the first Trump administration, they tried work requirements. The rules tied Medicaid eligibility to work requirements in several states.
For example, Arkansas tried and failed to impose work eligibility requirements because it couldn’t get the message out to those who needed to hear it. The state’s website went down repeatedly. Letters to recipients contained confusing language that people did not read or could not understand. Many people did not even hear about the new rules. In Arkansas, the ranks of the uninsured swelled by 18,000, while studies showed there was no change in employment. In short, working people were simply losing their healthcare under Medicaid. They weren’t lazy do-nothings who would somehow head back to work to maintain their Medicaid eligibility.
Things didn’t go well in Georgia, either. Laura Harker, a senior health policy analyst at the Center on Budget and Policy Priorities, summarized that state’s failed program. She noted that Georgia had not opted for Medicaid expansion under the Affordable Care Act. Instead, it applied for a waiver to provide Medicaid, conditioned on meeting work requirements, under a program called “Pathways to Coverage.” Adults with low incomes had to report at least 80 hours of work or volunteer activities each month as a condition of getting and keeping their coverage. That is basically what the new proposed federal Medicaid work requirements would also mandate nationwide.
So how did it go? Not well. Wrote Harker, “The results from over one year of Pathways to Coverage are in:
About 5,500 people were covered as of November 2024, far fewer than the 110,000 who initially expressed interest, and well under the about 240,000 uninsured people estimated to potentially be eligible for Pathways.
Application backlogs, excessive paperwork, and complex rules have left people waiting for coverage after they’ve applied and kept many other people from even applying for the program.
Spending on administrative changes, such as systems updates, eclipsed spending on healthcare services and offered little return on investment in facilitating enrollment.
"[W]ork requirements are the worst sort of red tape—blocking health coverage for working people, people with serious health conditions and people with disabilities," said Harker.
Then there was Michigan. Work requirements were codified into law in 2018 and lasted two years until a federal judge invalidated them as inconsistent with the Medicaid statute. That was long enough for Michigan to try to implement the new rules.
According to an account by Robert Gordon, the official in Michigan tasked with implementing the work requirements, despite their best efforts the state still saw nearly 100,000 people become ineligible for Medicaid benefits despite a massive and coordinated effort to inform recipients of the new rules. These eligible recipients only wound up keeping their benefits because of the court ruling.
So why didn’t this work?
Michigan had already seen what happened in Arkansas and thought it could do better. It spent $30 million on implementation. It went all out to modernize its systems for the change and let Michiganders know of the new rules, including
reprogramming the state’s Medicaid eligibility systems;
capturing employment and claims data;
modifying online application portals and written applications;
creating an automatic phone voice response system for work reporting;
establishing a call center;
launching a reminder campaign with text messages and outbound calls;
engaging the workforce to capture enrollees’ activities related to work;
developing outreach toolkits;
partnering with insurers, health providers, and community-based organizations to spread the word through regional forums, webinars, and other events; and
hiring 43 new state employees to conduct verification and audit activities.
As Gordon noted, Michigan set out to
take America’s longest benefits application and make it a national model. DHHS trimmed 42 complex pages to 18 straightforward pages that 90 percent of recipients could complete, online or in person, in 20 minutes or less. DHHS used the same human-centered design principles to create simpler notices about work requirements. “Don’t lose your health coverage!” a key letter blared.
Despite these efforts, the state estimated that around 100,000 people still were set to lose their Medicaid coverage. Again, most of these people, as in Arkansas, were actually eligible for these benefits. In Arkansas, less than four percent of those targeted for work requirements weren’t already working or exempt from them. But 100,000 Medicaid recipients in Michigan would have lost their benefits anyway because they still did not know about the rule change or could not overcome the administrative hurdles, despite the state’s concerted attempt to inform them.
As KFF noted, “Evidence shows Medicaid work and reporting requirements are confusing to enrollees and complex and costly for states to implement.” The states wind up with huge new administrative costs while providing fewer actual benefits.
Bottom line? Work requirements are really just Medicaid suppression.
Who would these work requirements really impact?
Republicans want you to imagine young men on their couches receiving Medicaid while playing video games instead of out working. So let’s paint the real picture.
As the Center for American Progress (CAP) reported, Medicaid work requirements target eligible workers in sectors with high rates of turnover and high percentages of seasonal jobs. That means millions of workers in manufacturing, agricultural, and service sector jobs such as retail, leisure, and hospitality would be among the first to lose their insurance should these work requirements be imposed.
How does this translate? Per CAP,
An April 2025 analysis from the Brookings Institution estimates that work reporting requirements would lead to a 27 percent reduction in Medicaid enrollment in the first year of implementation and a 34 percent reduction in subsequent years on average. This comports with an analysis from the Urban Institute estimating that work requirements would lead to 34 percent to 39 percent of all Medicaid expansion enrollees losing coverage.
But what’s so hard about meeting these work requirements?
For starters, they require frequent submissions of documentation of employment or job search efforts. That kind of paperwork is particularly challenging for workers in these industries, who are in and out of jobs constantly. Keeping and producing so many records would be challenging for anyone, let alone those whose first language may not be English or whose job takes them away from their homes for long periods.
Many understandably give up after finding they can’t travel to the state offices to prove eligibility, or don’t have time to wait in line or on long telephone holds. Many don’t have the ability to upload “evidence” of their work online.
You get the picture, and so does the GOP. Again, it knows that imposing these requirements means cutting off those most in need of Medicaid benefits.
And that’s precisely why they are turning to these work requirements to achieve their hundreds of billions in cost “savings.”
One more thing: The GOP understands how unpopular and horrific these cuts would be. So Republicans are gaming the system so that the worst of the effects won’t be felt until much later.
As the New York Times reported,
[D]espite the broad embrace of work requirements, the legislation notably delays implementation until January 2029, after the next presidential election.
That’s right. This craven move allows the GOP to claim it has achieved cost savings while pushing the political cost of the move off onto a different administration.
The proposed draconian cuts to Medicaid are by no means assured to pass. Vulnerable Republicans in swing districts will soon hear from outraged constituents and could still balk at the package. Far-right House members may still draw the line at raising the debt ceiling once again to fund deficit spending.
Meanwhile, over in the Senate, there are some unusual voices in opposition. These include Sen. Rand Paul (R-KY) who is a deficit hawk and has criticized his party for exploding the debt while not cutting spending. There’s also Sen. Josh Hawley (R-MO), whose state will be hard hit by Medicaid cuts and who wrote an OpEd in the New York Times urging the GOP to preserve Medicaid in order to truly become the party of the working class.
While many on the left are understandably uncomfortable making common cause with either of these two extremists, what will matter in the end is if Speaker Johnson and Senate Majority Leader Thune have the votes in their respective chambers to pass the budget through the reconciliation process. And that will in large part depend on how loud and angry the American public becomes over the proposed cuts in the coming weeks.
And note a third or more of Medicaid spending goes to seniors in nursing homes and poor seniors helping to pay Medicare premiums
Great deep dive into the weeds, Jay. Fascinating detail about the implementation date being January 2029. That deserves a WTF.