Republican divisions over changes to Medicaid — the federal health care program for poor, elderly and disabled Americans — are becoming the chief hurdle to getting President Trump's major tax, immigration and energy agenda through Congress.
GOP lawmakers who represent swing districts insist they will not vote for any proposal that strips benefits. But conservatives are demanding deep cuts in spending and say restructuring Medicaid is one of the clearest ways to achieve that goal.
Driving this discussion is a math issue. To get the bill through Congress, House Republicans are working with a budget blueprint that forces them to find $1.5 trillion in spending cuts to help offset the cost of extending Trump's 2017 tax cuts. They are also hoping to add new tax cuts that Trump campaigned on, like exempting taxes on tips, overtime and Social Security benefits.
Republicans want to finalize their plans next week in hopes of sending the package over to the Senate by Memorial Day. But in addition to the fight over Medicaid, the party is grappling with a host of other issues, including whether all of the Trump tax cuts will be renewed, food-assistance for low-income families and a controversial deduction for state and local taxes, or SALT.
On Thursday, House Speaker Mike Johnson, R-La., admitted that negotiators were still sussing out the specifics. But when it comes to Medicaid, he insisted that those who depend on the program will retain their benefits.
"Our true and honest intention is to ensure that every Medicaid beneficiary who is in that traditional community of folks, you're talking about young pregnant mothers and young single mothers and the elderly and disabled, those folks are covered, and no one loses their coverage," Johnson said.
That could be a hard promise to keep, according to health policy experts, who note that nearly 82 million people in the U.S. rely on Medicaid and the related Children's Health Insurance Program for their health coverage.
"While these federal cuts, in many cases, might not directly cut Medicaid coverage and benefits, they would indirectly have that result because states would be left holding the bag," said Larry Levitt, the executive vice president for health policy at KFF, a health policy organization.
"I think there's always been this perception in Washington that Medicare and Social Security are political third rails," Levitt said. "But I think what we're discovering is [that] Medicaid might be a third rail as well."
What Republicans are considering and what they've dropped
Johnson, under pressure from his own vulnerable members, has already pulled back on one proposal to restructure how states pay for an expansion to the Medicaid program that was included as part of the Affordable Care Act. The proposal would have decreased the percentage of costs that the federal government takes on — known as the Federal Medical Assistance Percentage, or FMAP — but in doing so would have shifted more costs onto already strapped state budgets.
Moderates insisted the option was a nonstarter and a new Congressional Budget Office report found it would have forced 2.4 million people to lose health care coverage by 2034.
But Republicans are still considering several other options, including:
Potential caps on spending. Some Republicans want to cap the amount that the government sends to states for Medicaid. Moderates have ruled this out for the full Medicaid population. However, some are entertaining caps for those who get coverage through the Medicaid expansion program. The expansion extended benefits to childless adults without disabilities — a group that some Republicans say is less in need than the program's traditional population.
Levitt says that capping spending would still shift costs to the states, albeit more slowly than other proposals, like FMAP changes.
"A per capita cap is almost more of a slow boil," Levitt said. "It would gradually reduce how much the federal government contributes for expanded Medicaid over time. So, you know, in the end they amount to the same thing. They just kind of roll out differently."
According to the CBO, placing caps on the Medicaid expansion population would lead to 1.5 million people losing health insurance over the next decade.
Work requirements. This idea has widespread support from Republican lawmakers who argue that able-bodied adults should have to meet some requirements to receive coverage. They say Democratic policies have significantly expanded the population covered by Medicaid. They maintain too many recipients now are working-age adults who should be required to show they are working or in training or education programs to be covered. Pregnant women, elderly people and children would not face the same requirements.
By enacting work requirements, the federal government is estimated to save $109 billion over 10 years, according to a CBO report commissioned in 2023 looking at able-bodied recipients, with no children, between the ages of 19 to 55. It also found that roughly 600,000 people would lose health insurance, but that the policy would not boost employment.
Adjusting the Medicaid enrollment period. The GOP proposal would shift Medicaid from an annual enrollment process to one that requires recipients to enroll every six months. It would also undo a Biden-era policy designed to ease enrollment and renewal for eligible Americans.
Cutting "waste fraud and abuse." Republicans have made this messaging key to their discussions on Medicaid, arguing that the government needs to ensure that resources are not misused.
The exact bounds of what policies and changes may fall under the category of "waste, fraud and abuse" is unclear. Some lawmakers, including Johnson, have pledged to remove Medicaid coverage for individuals living in the U.S. without legal status, but immigrants who are undocumented are not eligible to enroll in federally funded coverage.
Edwin Park, a research professor at Georgetown University's McCourt School of Public Policy, says GOP messaging on Medicaid is not new. He notes that proposals like expanded work requirements and per capita caps were all part of the Republican fight to repeal the ACA in 2017.
"These proposals are largely targeted at reducing coverage and enrollment, not trying to combat the very rare situation where there may be ineligible people enrolled," said Park.
"This fraud, waste and abuse message is just being used as a label for all these Medicaid cuts, which are long standing priorities, particularly for more conservative members of the Republican caucus," he said.
Internal divides and key deadlines
Hard-line conservatives see the $1.5 trillion in proposed cuts in the budget framework as merely a floor. They inserted language in the plan requiring smaller tax cuts if spending cuts end up below that level.
This week more than 30 House conservatives sent a letter to the speaker noting that the budget resolution the House approved set a target that's not up for negotiation.
"The House reconciliation instructions are binding. They set a floor for savings, not a ceiling. We must hold that line on fiscal discipline to put the country back on a sustainable path," the letter states.
To reach those cuts, Republicans should press for the broadest reforms possible to Medicaid, Rep. Chip Roy, R-Texas, told reporters on Thursday.
"The math has to add up. Very clear that we need to actually get the transformations we need in Medicaid so that you don't have the able bodied getting greater benefits than the vulnerable."
The speaker has set a goal of getting a package through the House by Memorial Day, and top GOP leaders say they believe they can negotiate a final package with the Senate and get it to the president by July 4.
Many swing state House Republicans say they need to coordinate final details on any Medicaid changes with the Senate, because requiring them to vote for something that is a nonstarter in the upper chamber opens them up to political attacks in the midterms.
New Jersey GOP Rep. Jeff Van Drew told reporters the discussion has to center on finding a deal that the president and the Senate can pass.
"What we don't want to do — I've been clear — is pass a bill through the House of Representatives that doesn't even have a shot with the president or with the United States Senate," he said. "That would be insane. It's stupid."
Sen. Josh Hawley, R-Mo., has already been vocal about his opposition to large changes to Medicaid.
"Everybody's got to make their own judgment and some folks are probably fine with cutting Medicaid," he told NPR last week. "They view that as a feature, not a bug, but I view it as a bug. I mean, I'm not going to vote for Medicaid cuts."
Rep. Dan Newhouse of Washington told reporters that when Republicans last tried to make significant changes to Medicaid in 2017, "it didn't work out so well." Newhouse said that in his own district, almost 40% of his constituents are on Medicaid.
"It's a huge issue. We want to make sure those people who need it have it available to them."
Oklahoma GOP Rep. Tom Cole says he supports proposals to increase the share that states pay for Medicaid. He says while he won't agree with every decision about every piece of the bill, the central question Republicans will have to answer is will they vote no and "trigger the largest [tax] increase in American history."
He says the way it's worked since President Trump took office in January is that the speaker "adroitly gets us to about the 10 yard line, and then you turn the ball over to Donald Trump" to lock up the votes to get over the goal line."
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