The Stealth Way the Republicans Plan to Cut Medicaid

President Trump insists that Medicaid will not be cut. The House leadership agrees. This insistence is not an accident. Most polling shows strong bipartisan opposition to Medicaid cuts, and a large number of Trump’s core supporters are on Medicaid. As the KFF Tracking poll found, “Opposition to a reduction in federal spending on Medicaid may reflect the fact that most people view Medicaid as important for their families and communities and most have a personal connection to the program.”

Math, however, makes these promises impossible to keep. The House budget resolution instructs the House Energy & Commerce Committee to reduce the federal deficit by $880 billion over ten years. Here is the math problem: Medicaid comprises $8.2 trillion of the $8.6 trillion in spending controlled by the committee. Even if the Committee were to zero out all of the other federal programs under its jurisdiction, it would still need to cut $400 billion in Medicaid spending.

So how do Republicans plan to solve this math problem while still insisting that they are not doing so? A cruel sleight of hand that will dump millions of people off the Medicaid rolls: by imposing work requirements on Medicaid recipients.

Politically, this may be a smart political move in the short term. The latest KFF Tracking poll finds substantial public support for work requirements. “Overall, about six in ten (62%) adults say they support Medicaid work requirements, while about four in ten (38%) oppose. Majorities of Republicans (82%) and independents (60%) support such a requirement, while Democrats are more split (47% support, 53% oppose).”

In the long term, however, this may not be the political winner the Republicans think it will be as voters find that their friends, family and neighbors are losing health coverage even though they are working or unable to do so.

So what’s wrong with requiring able-bodied adults to work? In short, it addresses a problem that doesn’t exist—the vast majority of Medicaid recipients able to work, do work. The insidious nature of work requirements is that they impose onerous reporting requirements on recipients and reduce the rolls by denying benefits to those who made administrative errors.

The fact is that very few Medicaid recipients who are able to work fail to do so. Accordingly to an KFF analysis of the March 2024 Current Population Survey, “92% were working full or part-time (64%), or not working due to caregiving responsibilities (12%), illness or disability (10%), or school attendance (7%). The remaining 8% of Medicaid adults reported that they are retired, unable to find work, or were not working for another reason.” It is no surprise therefore that the Congressional Budget Office estimated in 2023 that work requirements would result in 1.5 million recipients losing coverage, but would not increase employment.

So how can this be? How can a work requirement result in millions of people losing coverage when most recipients are already working? As E.J. Dionne Jr. explains, work requirements use red tape to remove people from the rolls:

Work requirements would do little to promote work (let alone impact video-game playing). What they would do is ensnare people in the sort of bureaucratic red tape that conservatives such as Johnson claim to despise. Working people who have every right to Medicaid — the folks behaving the way Johnson wants — could lose it in this regulatory maze.

Work requirements “take help away from people who are working because reporting weekly hours requires a cumbersome system that trips people up and because low-paid jobs often have fluctuating hours, and so someone can fall out of compliance because their employer cut their hours,” Parrott told me. “These policies also hurt workers who get laid off or lose their jobs because they are sick or need to care for a sick child,” she added.

The experience in Arkansas is instructive. In 2018, Arkansas was the first state to experiment with work requirements for Medicaid. The experience was not at all a happy one. A Harvard T.H. Chan School of Public Health analysis found that work requirements did not increase employment. In addition, “people in Arkansas ages 30–49 who had lost Medicaid in the prior year experienced adverse consequences: 50 percent reported serious problems paying off medical debt, 56 percent delayed care because of cost, and 64 percent delayed taking medications because of cost. These rates were significantly higher than among Arkansans who remained in Medicaid all year. Finally, awareness of the work requirements remained poor, with more than 70 percent of Arkansans unsure whether the policy was in effect.”

Fully one in four Medicaid recipients (18,000 people) lost coverage, and only a small number regained coverage the following year. This was not because they were loafers, but because of the red tape monthly reporting requirements that were unforgiving. Even people who were supposed to be exempt from the reporting requirement because they were disabled were forced off the rolls. The Center on Budget and Policy Priorities noted

Large numbers of people lost Medicaid for administrative reasons (a term called “administrative denials”) — not because they were not working. . . . This finding also supports research showing that many people had not heard about the requirement, were unsure if they received a letter in the mail notifying them about whether they were subject to the requirement or exempt, were already overwhelmed with stressful life events, or were concerned about their or others’ online access and skills.

The Arkansas program was so poorly designed that a cynic might wonder whether this was by design, but even states like Georgia that attempted to impose a more user-friendly work requirement found huge problems with administrative barriers preventing eligible people from enrolling.

If there were a large number of Medicaid recipients refusing to work, perhaps a work requirement might make sense. That, however, is not the case. We therefore need to see this for what it is—a stealth way to use red tape to force eligible recipients off the rolls and therefore making funds available for the Republican priorities.