The Looming Fight Over Medicaid

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Those of us who follow Donald Trump’s rhetoric on health care closely know that he has always talked about protecting Medicare while never mentioning Medicaid.

That changed this week, in the Trumpiest way possible.

The program that pays medical bills for more than 70 million low-income Americans has long been a target for Republicans looking to downsize or eliminate federal programs, especially those serving the poor. Trump’s past silence has felt like a reminder that he too wanted to strip funds from the program ― or, at least, that he had no problem with doing so.

Trump certainly seemed to support Medicaid cuts in 2017, when he was pushing hard for legislation to repeal the Affordable Care Act, aka Obamacare. Had that legislation passed, it would have slashed Medicaid and, in the process, deprived millions of health insurance.

But on Tuesday, while appearing with adviser Elon Musk on Sean Hannity’s Fox News show, Trump actually mentioned Medicaid ― and said, quite plainly, that he did not plan to cut it. “Medicare, Medicaid, none of that stuff is going to be touched,” Trump said.

That was big news, and timely too, because House Republicans are right now moving forward with a budget plan that will likely include precisely the sort of Medicaid cuts Trump was saying he wouldn’t support.

On Wednesday, literally one day later, Trump wrote a social media post in which he endorsed the House budget and said he preferred it to the Senate alternative ― which, among other things, does not have Medicaid cuts.

The apparent reversal confused everyone, including some reporters at Politico who queried the White House. They were seeking clarification. They didn’t get it, because the press office sent two statements ― one promising Trump would protect Medicare and Medicaid and then, just a few hours later, an “updated” version that was conspicuously missing the Medicaid reference.

There’s nothing new about Trump making wildly inconsistent statements, or his staff tripping over themselves to explain what the boss really thinks on a vital issue. Quite possibly they don’t know, and quite possibly Trump himself doesn’t know, given how little interest he often shows in policy. It would frankly be a surprise if Trump understood the program well enough to have a strong opinion.

But that also suggests he has no commitment to protecting Medicaid, which could leave it vulnerable to major cuts as Republicans search desperately for ways to offset their proposed tax reductions.

Medicaid is the fourth-biggest spending item in the federal budget. And unlike the three items ahead of it (Social Security, Medicare, defense spending) it serves poor people exclusively. Historically, those sorts of programs have been the toughest to defend against legislators eager to slash funds.

But Trump’s rhetorical shifts this week tell us something else, too: He understands Medicaid matters to a lot of people. That could be the key to saving the program, if its defenders act in time.

Medicaid is in many respects the accidental child of America’s health care system. It was practically an afterthought in the debate leading up to enactment of the 1965 Social Security amendments, whose centerpiece was the creation of Medicare, the federal health insurance program for the elderly.

When Lyndon Johnson signed the bill into law, Medicaid didn’t even make the front page in the New York Times coverage, as veteran health care journalist Joanne Kenen noted recently in Politico.

But in the ensuing decades, creative and determined supporters like the former Rep. Henry Waxman (D-Calif.), found ways to expand it to cover ever more services and ever more categories of people. The biggest single expansion came in 2010, when the Affordable Care Act gave states the money to cover anybody with income below or just above the poverty line.

Most states have now done that, and it’s the single biggest reason the percentage of Americans without health insurance has reached historic lows.

That growth has also drawn the ire of conservative Republicans, who have said Medicaid puts too big a burden on the taxpayers ― and who see it as an inefficient welfare program that discourages poor people from working. Efforts to reduce and cap the federal government’s financial commitment to Medicaid date back to the Reagan era. And they nearly succeeded in 2017, when Republicans came close to actually repealing the Affordable Care Act.

That was also the moment when the program’s surprising political resilience became clear. The GOP proposals provoked an outcry from people who stood to lose coverage ― not just working adults, but also senior citizens and people with disabilities, many of whom rely on Medicaid to pay for home care or nursing homes.

That coalition today is, if anything, bigger than it was back then. Something like two-thirds of Americans have been on Medicaid or have a family member who has been, according to surveys from the research organization KFF. It has also become a financial lifeline for the health care industry, especially hospitals that serve large numbers of low-income residents.

Not coincidentally, Medicaid is seen favorably by the majority of Americans — and even the majority of Republicans — according to KFF polling. And cuts could hit disproportionately hard in areas that tend to support Trump.

Republicans understand this, and not just in the White House. Longtime Trump supporter and MAGA leader Steve Bannon warned during a Fox News interview last week that “Medicaid is going to be a complicated one. You just can’t take a meat ax to it, although I would love to.”

Sen. Josh Hawley (R-Mo.) went even further this week, telling HuffPost’s Igor Bobic that “I don’t like the idea of massive Medicaid cuts.” A day later, eight moderate House Republicans wrote a letter to Speaker Mike Johnson (R-La.) warning that “slashing Medicaid would have serious consequences, particularly in rural and predominantly Hispanic communities where hospitals and nursing homes are already struggling to keep their doors open.”

Nobody who has watched Republicans grumble about the lack of qualifications for Trump nominees and then vote to confirm them anyway would be surprised to see these same lawmakers vote for Medicaid cuts if a bill is put in front of them. And GOP leaders are already laying the rhetorical groundwork, saying their target is waste, inefficiency and abuse — something Trump has mentioned in his statements, as well.

Convoluted, duplicative and sometimes downright illegal payment arrangements are pretty much endemic to American health care, public and private. Medicaid is no exception. And although “waste” is a broad category that includes a lot of meaningless documentation errors ― as the left-leaning Center on Budget and Policy Priorities has noted ― it also includes funding schemes some states use to draw extra federal matching funds without putting up more of their own.

One of the Medicaid changes Republicans are discussing now would seek to end those practices. The Paragon Institute, a conservative organization that supports the proposal, has noted that Barack Obama proposed a version during his presidency.

But Obama did so in a very different time, and in the context of a proposal designed to expand health coverage overall. That does not seem to be the objective of Republicans in Congress, who also want to tie Medicaid eligibility to employment status. These “work requirements” don’t actually get more people to work, research has shown repeatedly. But they make the verification process so cumbersome that lots of eligible people end up losing coverage.

And whatever the reality and merits of these GOP efforts to reduce waste and fraud, getting the savings they need would inevitably require even bigger changes to the program ― the kinds of sweeping cuts that the public has clearly rejected in the past.

That’s especially true because, as several budget experts have noted, the proposals Republicans have floated would interact with each other in ways that would likely produce even fewer savings than their public budget documents predict.

“There’s not a pile of Medicaid dollars sitting in a corner labeled ‘waste, fraud, and abuse,’ “ Adrianna McIntyre, a professor at the Harvard School of Public Health, told HuffPost. “Steep cuts to the program will ultimately mean some combination of fewer people insured, fewer benefits covered, and lower payments to doctors and hospitals.”

How this all registers politically remains to be seen. The backlash in 2017 mattered because Democrats and their allies made it matter, especially at the grassroots. They fired off letters and emails and flooded the phone lines of congressional offices. And they showed up in person, through protests at town hall meetings — and eventually on Capitol Hill, too.

The backlash was all over the media, and the impact lasted. The GOP took a beating in the subsequent midterm elections, losing control of the House. Analysts think the backlash to the Obamacare repeal attempt was a big factor in that.

Saving Medicaid now might take a similar effort. But this time around, there’s an added layer of complication: The program’s defenders can’t count upon traditional media to carry their message to lawmakers — or to the public. Going viral on Instagram or TikTok may count as much as, if not more than, getting a story on the local news. And lately Republicans and their supporters have seemed more adept at deploying social media than Democrats.

But the defenders of Medicaid still have a lot going for them, too, even beyond the large and growing number of people who have first-hand knowledge of ― and appreciation for ― what the program provides. Health care is among the issues where voters traditionally trust Democrats more than Republicans.

There’s a reason for that: Democrats have always been the party fighting to expand and defend government programs that help people get health care, while Republicans have always been the party resisting those efforts ― and trying to roll back the programs already in place. That’s as true now as it’s ever been. The future of Medicaid could depend on making sure the public realizes it.