Gutting Medicaid With Work Requirements

The GOP has had their eyes on Medicaid for some time. Part of the reason for this stems from the nature of the program. Medicaid is a means-tested program that people above a certain income (it varies from state to state) are not eligible for. Unlike Medicare and Social Security, which almost everyone will use provided they reach retirement age, Medicaid is a program whose beneficiaries are by and large unorganized and without much political power. Additionally, the Medicaid expansion initiated by the Affordable Care Act, which expanded Medicaid coverage to an additional twenty million people, has been one of the few success stories of the welfare state over the last few decades.

Finally, Medicaid spending is genuinely massive — the state of California spends about $170 billion a year on its Medicaid program (the federal government picks up about $100 million of it), which is about twice what the entire country spends on prisons. All of this has made the program a prime target for Republican budget cutters.

At the same time, Republicans are hoping to extend the tax cuts passed in Donald Trump’s first term. These tax cuts, which were the only substantial legislative accomplishment of Trump’s first term, were massively skewed toward the rich. The average household in the top 1 percent of income earners received about $60,000, while the average of the bottom 80 percent of households received only $762.

All of this largesse for the rich was expensive; estimates are it will cost the government nearly $2 trillion over ten years. Because of this, a number of Republicans in Congress insist that any extension of the tax cut must be accompanied by spending cuts to prevent it from adding massively to the deficit. With a razor-thin majority in the House, these deficit hawks could sink any attempt by Trump and the GOP leadership to ram the cuts through in spite of their impact on the deficit. Finding a way to substantially cut Medicaid spending has thus become central to the larger GOP budget plan.

The problem for the GOP is that Medicaid is very popular. A supermajority of Americans have a favorable view of the program, and a recent poll found that only 17 percent of Republicans support cuts to it. Though Medicaid recipients may not be as well organized as retired people, the program has won wide support throughout the population.

As a result, Republicans are attempting to camouflage their cuts in the form of work requirements. Rather than simply cutting the budget, they say that instituting work requirements will lead people to get jobs and be able to pay for their own health insurance, saving the program money in the process. Moreover, unlike directly cutting Medicaid spending, work requirements are politically popular. A poll in 2023 found that fully two-thirds of Americans support work requirements for Medicaid and food stamps.

Yet cuts are all work requirements actually are. During the first Trump administration, states were granted waivers to institute work requirements. Only Arkansas actually implemented the policy, and the results are instructive. About a quarter of Medicaid recipients subject to the requirement (about 18,000 people) lost coverage while the waiver was in effect. Yet the requirement produced zero effect on employment. People kicked off Medicaid were no more likely to have jobs than they were while they were on it.

The reason for this is simple. Most people on Medicaid are already working. Among those that aren’t, most are either disabled, taking care of a family member, or going to school. There simply aren’t that many people on Medicaid who could go get a job, even if their health care is cut off. Moreover, work requirements often lead to people who technically shouldn’t be removed from the program being kicked off because they haven’t supplied the proper paperwork establishing their employment. Work requirements do nothing to make people work more. They simply kick people off the rolls.

Defending Medicaid

The campaign to defend Medicaid thus has its work cut out for it. While cuts to Medicaid are deeply unpopular, they become extremely popular if simply relabeled as work requirements. In other words, public opinion on this subject, as on many others, is inchoate and volatile. A movement dedicated to defending it has to redefine work requirements in the public mind; in doing so, it can defeat the attempt to gut Medicaid to pay for tax cuts for Musk and his ilk.

The Republicans are also disorganized and vulnerable.

Just as in his last term, Trump has failed to provide any real direction or coordination for congressional Republicans. On February 6, he met with House Republicans, but only spoke briefly before leaving it up to the representatives to sort things out among themselves. In the House, the party remains divided between members who want to push Trump’s tax cuts through with or without accompanying budget cuts, and deficit hawks who are demanding that offsetting budget cuts be a condition of the tax policies.

Meanwhile, Senate Republicans have gone ahead and produced their own budget bill, which funds the government but does not include Trump’s tax cuts. While the legislative wing of the party may be unanimous in their sycophancy before Trump’s power grab in the executive, when it comes to their actual job of writing legislation, they are far more divided.

Defeating Medicaid cuts is an urgent priority over the coming months. It’s an opportunity to reestablish the popularity of the welfare state as a principle of American politics, and to hand Trump and the GOP a much-needed defeat. Because of the GOP’s disarray, it also has the potential to hamstring the party’s only substantive legislative priority. Finally, this kind of work can provide some balance and ability for longer-term coordination amid the daily outrage that the administration is committing. The Left should not let this opportunity slip by.