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Medicaid is popular. So why are Republicans still trying to cut it?

The flawed assumptions of the House GOP’s revived plan for work requirements.

A photo of Kevin McCarthy speaking.
In a Wall Street speech this week, House Speaker Kevin McCarthy laid out his party’s plans for the upcoming federal debt-limit negotiations, likely to include a proposed Medicaid work requirement.
Michael Nagle/Bloomberg via Getty Images
Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

The House Republican majority has released its demands for major government spending cuts in exchange for increasing the federal debt limit. And they include a familiar target for conservatives: Medicaid.

It’s a gambit that may be more than a decade out of a date and could pose a political risk to the party. For years, Republicans have believed that Medicaid, which primarily serves low-income Americans, is less politically potent than Medicare or Social Security, two of the other core features of the US social safety net, and therefore a safer target for proposed cuts.

There may be some truth to that notion — but Medicaid is plenty popular on its own terms. Over the past two decades, the health insurance program has become an increasingly crucial part of the safety net. Enrollment has roughly doubled from about 46 million people in 2007 before the Great Recession to more than 92 million today. More than 75 percent of the US public says they have very or somewhat favorable views of the program. Two-thirds say they have some kind of connection to Medicaid, either because they themselves or a loved one was enrolled.

In state after state, when the question of expanding Medicaid to working-age, childless adults has been put to voters in red states, they’ve voted in favor of giving more people access to health insurance. Even the Republican legislature in North Carolina recently made peace with expanding the program.

The House’s work requirement proposal — dubbed a “community engagement” requirement in the bill’s text — would roll back those coverage gains by requiring many recipients to be working, looking for work, or participating in another kind of community service. Children under 18, adults over 56, people with mental or physical disabilities, and parents of dependent children would be exempted.

The Congressional Budget Office has previously estimated requiring non-disabled, non-elderly childless adults to work in order to receive Medicaid benefits would slash the program’s spending by $135 billion over 10 years — largely because more than 2 million people would lose coverage for failing to meet the work requirement.

The last time Republicans tried (and failed) to pass significant cuts to the Medicaid program, in the first year of the Trump presidency as part of their Affordable Care Act repeal plans, they paid the price during the 2018 midterm elections. So if Medicaid has proven popular quite recently, why have Republicans seemingly convinced themselves that they can try to cut it again without penalty?

The answer is partly about the method they’ve chosen to cut the program: work requirements, which leaders think will go over well in competitive congressional districts. But it’s also about how Republicans have (in some cases reluctantly) embraced other facets of the social safety net, leaving themselves with few other options.

The GOP has tried to cut other social welfare programs and failed

Once upon a time, conservatives wanted to remake Social Security and Medicare just as eagerly as they still wish to overhaul Medicaid.

President George W. Bush invested much of his political capital in his second term in pursuing his doomed attempt to privatize Social Security. Paul Ryan, who became the party’s intellectual leader in the early 2010s as the Tea Party backlash to President Barack Obama was rising, made further privatizing Medicare a central plank of the Republican platform.

But those proposals proved politically disastrous. Democrats campaigned against Bush’s Social Security proposal when they gained seats in the 2006 midterms. The 2012 Obama campaign hung Ryan’s Medicare overhaul on Mitt Romney, who had picked Ryan to be his vice presidential candidate.

Then in 2016, the window for so-called entitlement reform slammed shut. Donald Trump bulldozed through the Republican primary, where he promised not to cut Medicare and Social Security as so many GOP candidates before him had pledged to do. When Republicans retook the House in 2022 and began plotting for the pending debt-limit debate, they preemptively took Medicare and Social Security cuts off the table.

But there’s a reason Republicans had targeted those programs in the past: they are two of the biggest outlays in the federal budget. Social Security alone accounts for 20 percent of federal spending. Medicare covers another 12 percent or so. If you assume Republicans are unwilling to cut defense spending and veterans benefits, that means almost half of the federal budget is off limits from the start.

So what is the GOP willing to cut, or at least to propose cutting to start its negotiations with the Biden White House and Senate Democrats? Enter Medicaid. In a Monday speech given at the New York Stock Exchange, House Speaker Kevin McCarthy laid out his party’s priorities in the debt-ceiling talks and sought to justify their proposed cuts to social programs. He said he wanted the government to give Americans “a hand up, not a handout.”

There is a certain logic to Republicans’ commitment to pursuing Medicaid cuts: Social Security and Medicare are universal programs. Everyone pays in while they work, and then enjoys the benefits when they retire. Medicaid, on the other hand, is targeted to people who have low incomes. Republicans argue that this program, like food stamps and cash welfare, discourages people from seeking work, since they only qualify for benefits if their income is below a certain threshold.

“Assistance programs are supposed to be temporary, not permanent,” McCarthy said. “A hand up, not a handout. A bridge to independence, not a barrier.”

The problem is their diagnosis may be wrong. For starters, about two-thirds of the people covered by Medicaid — those who are children, elderly, or disabled — are usually exempted from work requirement proposals. Working-age adults who are expected to meet them can end up losing coverage even if they are attempting to satisfy it, if they have irregular work hours for example, or if they have trouble filing the necessary paperwork. One estimate of a Medicaid work requirement proposal in Michigan found that only about one-quarter of the people expected to lose their coverage were considered “out of work,” meaning they could work but weren’t. The rest were already working, retired, caring for a loved home at home, or unable to work for some other reason.

In Arkansas, where implementation of a work requirement was eventually blocked by a court order, nearly 17,000 people lost coverage after the requirement was put in place. Analyses later found that Medicaid beneficiaries had not started working more or earning more money as a result of the policy. Instead, lots of people got kicked off Medicaid, but it didn’t lead to an improvement in their economic status; they simply became uninsured.

Still, a little more than half of the Republican base continues to consider Medicaid more akin to welfare than health care. Punchbowl News reported that internal House GOP polling showed that work requirements were popular among voters in the competitive districts that will determine future House control.

Public polling suggests it’s a little more complicated than that. As I wrote in 2018, Americans are of two minds about work requirements. When asked if they support requiring work in order to receive certain government benefits, the public will generally say yes. But when those policies are framed differently, and particularly when they are portrayed as cuts, their popularity drops.

That is the risk for House Republicans in this debt-ceiling gambit: Medicaid spending cuts are deeply unpopular with both the American public and lawmakers. Two-thirds of Americans now say they oppose cutting Medicaid’s spending.

There’s even a risk that the GOP’s attempts to overhaul the program could further reinforce its popularity. An analysis published last year in the American Political Science Review studied the effects of the party’s attempts to repeal the Affordable Care Act, of which Medicaid expansion is a core part. The threat to the law helped to solidify its standing with the public, partly because Republican voters became more resistant to the possibility of losing benefits. Two of the Republican senators who doomed the party’s plans cited the Medicaid cuts as a major factor in their vote.

And yet, the GOP continues to pursue Medicaid cuts — perhaps because, on other programs, they have boxed themselves in.