House Budget Committee Chairman Jodey Arrington, R-Texas, (center), alongside Rep. Brendan Boyle, D-Pa., the ranking member (left), and Rep. Ralph Norman, R-S.C., (right). House Republicans strategize on a budget plan aimed at advancing President Trump’s initiatives, which include $4.5 trillion in tax cuts, on Capitol Hill in Washington on February 13.
J. Scott Applewhite/AP
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J. Scott Applewhite/AP
The future of Medicaid is once again precarious.
Republicans, who hold a slender majority in Congress, are advancing proposals that could significantly reduce funding for the government-sponsored health insurance program for low-income and disabled individuals as a way to support President Trump’s agenda for tax reduction and border security.
Democrats are rallying to counteract the GOP initiatives and defend Medicaid funding by garnering backing from hospitals, governors, and advocacy groups for consumers.
The implications are vast, potentially affecting coverage for approximately 79 million individuals enrolled in Medicaid as well as its associated Children’s Health Insurance Program. This also concerns the financial viability of thousands of hospitals and community health centers and represents a substantial revenue source for all states.
On February 13, the House Budget Committee voted to pursue at least $880 billion in mandatory expenditure reductions on programs monitored by the House Energy and Commerce Committee, which oversees Medicaid and is expected to endure a significant share of these reductions.
Senate Republicans, crafting their own strategy, have not suggested similarly deep cuts. Senator Ron Wyden of Oregon, the leading Democrat on the Finance Committee, expressed his anticipation of an effort to obscure the impending Medicaid cuts, warning they will emerge either now or later.
Since President Trump took office, discussions among Republicans have focused on overhauling Medicaid, especially by imposing work requirements for enrollees. Critics argue that most enrollees are already engaged in work, education, or caregiving, and that such a mandate would merely create additional bureaucratic obstacles to obtain coverage without noticeably affecting workforce participation.
Other Republican proposals gaining traction towards achieving budget cuts may involve diminishing the federal government’s financial responsibility for certain enrollees or for the program overall.
Both President Trump and House Speaker Mike Johnson assert they aim solely to eliminate “waste, fraud, and abuse” in the program, although they have yet to provide concrete examples or details of such concerns.
Trump has indicated he would “love and cherish” not only Medicaid but also Medicare. In a Fox News interview broadcast on February 18, he reiterated his assurance that Medicaid, along with Social Security and Medicare, would not be “touched.”
Recognized as a fundamental component of the U.S. health system, Medicaid serves Americans at every stage of life, covering four in ten births and healthcare expenses for over 60% of nursing home residents. The program operates as a partnership between state and federal governments, with the federal level providing the majority of funding and matching state contributions irrespective of enrollment numbers.
This summer marks the 60th anniversary of Medicaid, which was established as part of President Lyndon B. Johnson’s “Great Society” initiative aimed at combating poverty, alongside Medicare, which is the federal health insurance scheme for individuals aged 65 and older.
In today’s intensely polarized political environment, few issues starkly illustrate the ideological divide between the two major parties like Medicaid does.
While Democrats view Medicaid as a vital mechanism to ensure healthcare accessibility and affordability across income levels, many Republicans perceive it as a flawed and inefficient welfare system that has expanded too drastically and serves millions of adults who should not be receiving government support. Several Republican lawmakers argue that “able-bodied” adults ought to secure coverage through employment or by purchasing insurance independently.
The majority of Republicans opposed the 2010 Affordable Care Act (ACA), which broadened Medicaid by providing coverage to millions of low-income adults and facilitating progress toward Democrats’ long-cherished aspiration of universal health coverage. In exchange for the expanded Medicaid eligibility, the federal government offered states a more favorable funding match to cover new enrollees.
However, while the majority of states led by Republicans accepted federal expansion funds—some only after voter approval of initiatives supporting Medicaid expansion—GOP leaders in Congress have stayed firmly opposed to the program’s growth.
When Republicans last held power in both Congress and the White House, they aimed at significant reductions in Medicaid in 2017 during attempts to repeal and replace the ACA. That initiative faltered by a slight margin, partly due to apprehension among several congressional Republicans over the potential harm it could cause to Medicaid and the associated private industry of health plans and hospitals.
Now, a more conservative faction of the GOP has once again set its sights on Medicaid’s budget, which has increased at least $300 billion over the past eight years, largely due to the COVID-19 pandemic and additional states choosing to expand Medicaid. The House budget draft is on a quest to uncover $4.5 trillion to reinstate Trump’s tax cuts from 2017, which are set to expire at the year’s end.
“Medicaid is increasingly becoming a focal point of partisan conflict in Washington,” mentioned Jonathan Oberlander, a health policy professor at the University of North Carolina and editor of the Journal of Health Politics, Policy and Law. “This is not just a response to Medicaid expansion under the ACA; it indicates a broader shift in the politics surrounding Medicaid, placing it in a vulnerable position.”
Medicaid represents an appealing target for Republicans for a multitude of reasons, beyond its sheer magnitude, Oberlander explains. “Primarily, they need savings from Medicaid to help finance the costs associated with extending the 2017 tax cuts,” he noted, emphasizing that Trump has excluded cuts to Medicare, Social Security, and national defense, which are the other most expensive government programs.
Additionally, GOP proposed cuts would contribute to scaling down the program, which served 93 million people at its highest during the COVID pandemic when states faced restrictions on terminating coverage for enrollees for a three-year span. Oberlander pointed out that such reductions also present an opportunity for Republicans to counter the ACA, often referred to as Obamacare.
The latest Republican efforts to revise Medicaid unfurl against a backdrop where Medicaid expansion has become ingrained in the majority of states—and their financial frameworks—over the past decade. Without federal expansion funding, states would encounter significant challenges in affording coverage for low-income populations on the program unless they opted to raise taxes, curtail benefits, or reduce spending on other sectors such as education.
Since the start of Trump’s term, additional red states like Utah, Oklahoma, Idaho, and Missouri have expanded the program, which has contributed to a decline in the nation’s uninsured rate to historic lows in recent times.
Medicaid enjoys significant public favor, with approximately 75% of Americans having a favorable view of the program, according to a KFF poll conducted in January 2025, reinforcing similar findings from 2017.
The GOP is reportedly considering various strategies to mitigate the scale of Medicaid, including:
Reducing ACA Medicaid support. Through Medicaid expansion, the ACA allocated funding for the program to cover adults earning up to 138% of the federal poverty line, which translates to $21,597 for an individual. The federal government covers 90% of the costs for adults who gain coverage through this expansion, which has been adopted by 40 states along with Washington, D.C. The GOP could propose to lower that funding to match the rate received by the federal government for all other beneficiaries, which averages around 60%.
Transitioning to block or per capita grants. These proposals could reduce federal support for states in managing Medicaid while granting them greater leverage regarding fund allocation. Annual block grants would establish a fixed funding amount for states regardless of enrollment figures. In contrast, per capita grants would distribute funds based on each state’s enrollee count. Currently, the federal government matches a certain proportion of state expenditures with no cap. Restricting federal funding would thwart Medicaid’s capability to assist states in economic downturns, during which the demand for coverage surges, while states have fewer tax revenues accessible.
Introducing work requirements. Republicans in Washington are aiming to embed work requirements into federal legislation. During Trump’s first term, his administration allowed several states to condition coverage for adults based on their employment status, with exemptions for caregiving or educational pursuits. Arkansas was the first state to implement this rule, resulting in 18,000 individuals losing their coverage there. In 2018, federal judges ruled that Medicaid law doesn’t permit work requirements, resulting in a cessation of attempts led by Trump and various states during his first term. Nevertheless, some states, including Ohio and Montana, are taking steps to impose such mandates.
Lawrence Jacobs, the founder and director of the University of Minnesota’s Center for the Study of Politics and Governance, warned that Republicans may face internal disagreements regarding any substantial cuts to Medicaid, especially if House members are cautioned that such reductions could lead to hospital closures in their constituencies.
America’s Essential Hospitals, a trade organization representing safety-net hospitals that cater to disadvantaged populations, is urging its members to engage with their lawmakers to clarify not just the potential ramifications of the cuts on patients, but also how they could trigger job losses and diminish services that would affect entire communities.
“The proposed cuts would be extraordinarily damaging and catastrophic for our hospitals,” remarked Beth Feldpush, the group’s senior vice president of policy and advocacy.
Jacobs added, “The politics surrounding Medicaid cuts are highly complex, and predictions about what will occur are difficult to ascertain at this juncture.”
KFF Health News is a national newsroom dedicated to providing in-depth journalism on health issues and is a core operating program at KFF.
