Medicaid Could Get Hammered If Trump Wins

One of Donald Trump’s best-known promises ― and quite possibly one of his most important, politically ― is his vow to preserve two of America’s most beloved government programs.

“I am going to protect Social Security and Medicare,” Trump said in his July speech at the Republican National Convention, repeating a line he’d said many times before and would say many times afterwards.

But Trump didn’t mention another vital program: Medicaid, which pays medical bills for roughly one in five low-income Americans. This omission does not appear to be accidental.

When HuffPost asked the Trump campaign last month whether the Republican nominee would extend his no-cuts pledge to Medicaid, the campaign offered a vague, bland response.

“As President Trump said, he will release more details but his overall position on healthcare remains the same: bring down costs and increase the quality of care by improving competition in the marketplace,” national press secretary Karoline Leavitt said in a statement emailed to HuffPost.

That non-denial denial is just one of several reasons to think Trump and Republicans might in fact target Medicaid if they get the chance. And while it’s an open question whether they would be able to get major cuts all the way through Congress, the consequences would be substantial, for the federal budget and for the many millions of Americans who depend on the program.

It would be the type of policy stance that might matter to voters in a presidential election — at least, if they knew about it.

Medicaid had nearly 73 million enrollees as of June, a number that includes low-income children and working-age Americans, for whom the program covers nearly all medical bills. It also includes several million low-income seniors and people with disabilities who use Medicaid to pay for nursing homes, prescription drug copayments and other expenses that their Medicare policies do not.

Democrats and other champions of the program generally consider Medicaid a success ― not because they think it’s perfect, but because of the financial security, access to medicine and improvements in health it provides to a large group of economically vulnerable Americans. Among other things, the program’s defenders note, a dramatic expansion of Medicaid through the Affordable Care Act is the primary reason America’s uninsured rate has reached record lows.

Republicans have a very different view of Medicaid. They see a bloated, inefficient program that they say yields few benefits and disincentivizes low-income people from working — all at a massive, economy-distorting cost to the taxpayer. Medicaid is now one of the biggest single line items in the federal budget, with annual expenditures that exceed $500 billion. That doesn’t even include the more than $200 billion contributed by states, which manage the program.

And so while Democrats have spent decades pushing to expand Medicaid, as part of their long-term project to get to universal health insurance, Republicans have spent decades trying to limit, cut or replace the program, as part of their long-term project to downsize the federal government and reduce direct income transfers from the wealthy to the poor.

Republicans in Congress pushed hard for Medicaid cuts throughout the 1990s and then again in the 2010s. Former House Speaker Paul Ryan (R-Wis.) once famously said he’d been “dreaming” of capping Medicaid funding since he was “drinking out of kegs” in college.

The specifics of the various Republican proposals have varied, but the underlying concept has been consistent: Change Medicaid from an open-ended entitlement that expands to meet the demand for it, no matter how many people qualify, into a program with some kind of predetermined spending formula that would likely not keep up with rising health care costs, increases in financial need or both.

Such a transformation would leave more responsibility for funding Medicaid to states ― which, under those past GOP plans, would also get more leeway to cap enrollment, limit services or otherwise scale back their coverage.

The closest Republicans came to making these sorts of changes to Medicaid was probably 2017, when they tucked such a proposal into legislation that would have repealed the Affordable Care Act. That bill would have reduced Medicaid spending by more than $800 billion over a decade and reduced enrollment by 14 million, according to Congressional Budget Office projections at the time.

Trump pushed Congress to pass the bill, which died when it couldn’t get through the Senate; he included large Medicaid cuts in budget proposals he submitted later in his term. And while Trump has been silent on the topic in this campaign, some of his top allies and advisers have called for Medicaid cuts in their proposed blueprints for a second Trump presidency.

This year’s official House Republican budget resolution, the most recently proposed budget from the House Republican Study Committee (which represents conservative Republicans) and the Heritage Foundation’s Project 2025 all contain some version of a proposal to reduce or limit Medicaid spending significantly.

“There isn’t a lot of detail,” Edwin Park, a Georgetown University research professor who has been documenting Republicans’ Medicaid plans in a series of blog posts, told HuffPost. “But they all have the same theme, which is a big cost shift to states and then new flexibilities, new options for states to make cuts, as a way to compensate for those cost shifts.”

“These can be dialed up or down, obviously, but they could involve hundreds of billions of dollars in Medicaid cuts, potentially trillions, over 10 years ― and then potentially many trillions in future decades,” Park went on.

Larry Levitt, executive vice president for health policy at the research organization KFF, told HuffPost such reductions would “leave states holding the bag and facing tough choices to cut spending elsewhere, limit Medicaid eligibility, reduce services, or cut payments to doctors and hospitals.”

“Much of Medicaid spending is for seniors getting long-term care and people with disabilities,” Levitt added, “so those groups would be particularly vulnerable.”

Trump of course has tried to distance himself from Project 2025, even though its contributor list is littered with current and former Trump advisers. And neither the Trump campaign nor Trump himself has said he’s committed to the House Republicans’ proposals.

But there’s one big reason to think Trump and Republicans would target Medicaid if they get the opportunity: They will need the money.

The top legislative priority for Republicans during a Trump presidency would almost certainly be cutting taxes — namely, a permanent extension of the cuts passed the last time Trump was in office. Those tax cuts are set to expire in 2025.

Making them permanent is likely to cost several trillion dollars, according to budget projections. And for a variety of reasons ― some having to do with the rules of the arcane budget process Republicans would likely need to use to get legislation through the Senate ― a GOP-led Congress would probably try to offset the costs of those tax cuts by also cutting something else.

If Medicare, Social Security and defense funding are all off the table, Medicaid would be the obvious place to turn, given that it’s the next biggest spending item in the budget. That’s one reason why close observers of health policy believe, as Maya Goldman of Axios noted back in August, that “no program is more in the crosshairs than Medicaid.”

Whether a serious effort to cut or limit Medicaid could succeed is difficult to say.

Over the years, Medicaid has proven politically resilient. The specter of so many people losing coverage loomed large in the defeat of the Obamacare repeal push in 2017. It came up at congressional town halls and drove protests on Capitol Hill. The possible impact of Medicaid cuts also figured prominently in the defeat of House Republican budgets during their 1990s showdowns with then-President Bill Clinton.

This wasn’t what many political professionals had expected, given that programs for poor people frequently lack powerful constituencies and carry the familiar stigmas of “welfare.” But many Americans have come to know and depend on Medicare personally.

Sometimes that’s because Medicaid finances long-term care for themselves or for relatives. Sometimes that’s because (especially following the Affordable Care Act) it provides insurance to adults in their lives who are working but don’t have coverage through their jobs.

Still, Medicaid survived past attempts to cut it because the public grasped the stakes. If that understanding comes too late, all bets are off.