By Andrew Sprung
Last month, as House Republicans teed up their federal spending blueprint for next ten years, President Trump forced them to try to square a circle. On Feb. 18, he promised that the pending budget resolution would not “touch” Medicaid. On Feb. 19, he enthusiastically endorsed the resolution, which calls for $880 billion in spending cuts from programs overseen by the House Energy and Commerce Committee – the vast majority of which would have to come out of Medicaid. Days later, House Republicans passed their budget resolution on a strict party line vote, 217-215.
How will Republicans honor Trump’s promise not to “touch” Medicaid while reducing federal funding for the program by hundreds of billions of dollars? Leave it to purported “moderate” U.S. Rep. Tom Kean Jr. (R-7th Dist.) to channel the emerging MAGA party line. On March 6, Kean told NorthJersey.com:
“I support strong Social Security, Medicare, and Medicaid programs for those who depend on them. Children, seniors, and those who are disabled rely on these crucial programs…I do not support these programs being riddled with waste, fraud, and abuse — that is a direct threat to their actual missions.”
While Kean vows to protect coverage for children, seniors and the disabled, note the group of Medicaid enrollees his vow excludes: low-income adults who are not on disability.
That’s the group rendered eligible for Medicaid by the Affordable Care Act. They are the “waste” Republicans propose to uninsure to help fund the resolution’s target $4.5 trillion in tax cuts for corporations and the wealthy.
Prior to the ACA, Medicaid primarily covered the aged, blind and disabled, as well as children and pregnant women. The ACA expanded eligibility to adults with income below 138% of the Federal Poverty Level – about $21,600 per year for a single adult in 2025.
To make the expansion affordable for states, the ACA created an enhanced federal contribution of 90% of costs for the expansion population. In other Medicaid categories, the feds pay “match rates” between 50% and about 80% — more for low income states, less for high-income states (New Jersey gets the 50% minimum).
The expansion, which 40 states and Washington, D.C. have enacted (after the Supreme Court made the expansion optional for states in 2012), has cut the uninsured rate about 40% nationwide.
It’s this “expansion” group that Republicans are likeliest to target when they write the spending bills to flesh out their budget resolution. Axios reported on March 5 that House Energy and Commerce Chair Brett Guthrie “is eyeing lowering the federal share of costs, or FMAP, for the expansion population, or even a per capita cap that applied only to the expansion group.”
Sources also told Axios that House Speaker Mike Johnson, a MAGA Republican, is likely on board with such a cut.
Ending the ACA’s 90% FMAP for the expansion population, a cut valued at $651 billion by the Congressional Budget Office, would make the expansion unaffordable for states and so would likely cause most of the 20 million adults currently insured through the expansion to lose coverage.
The Republican code word for those they’d like to uninsure is “able-bodied.” That’s a smear on those in need of government support that goes back centuries – implying that they’re unwilling to use their “able bodies” in productive labor.
Government largesse is “wasted” on them.
Republicans make frequent use of the term. From the MAGA point of view, a certain kind of Medicaid enrollee is “waste” – human waste.
Republicans will also likely put forward a less ambitious cut also motivated by antipathy to low-income adults: Imposing work requirements on adult Medicaid enrollees who don’t qualify for Supplemental Security Income (SSI).
The Congressional Budget Office estimates this change would “save” $100 billion. It would do so by throwing mostly eligible people off the rolls.
Work requirements poll well – but most Americans don’t realize that most Medicaid enrollees aged 19-64 who don’t qualify for SSI do work. In fact, 64% of such enrollees work, and another 28% are caregivers, students, or not working due to illness or disability, according to the Kaiser Family Foundation.
With encouragement from the first Trump administration, Arkansas gave work requirements a try in 2018 (other state proposals were blocked by the courts or turned down by the Biden administration). The state implemented an onerous and glitchy online reporting system for logging work hours or attempts to find work. About a quarter of those subjected to the reporting requirements – 18,000 enrollees – swiftly lost coverage. A court then shut the program down.
Take note, Republicans in Congress may require all states to establish such programs.
An array of other cuts are on the menu. All would reduce payment to states, and so would force states to cut service in as-yet-undetermined ways.
The New Jersey Department of Human Services has estimated the annual funding loss from various combinations of proposed cuts to range from $2.2 billion to $5.2 billion. In total, 1.85 million New Jerseyans are enrolled in Medicaid, 550,000 of them through the ACA expansion.
Some Republicans have pointed to accounting by the federal Center for Medicare and Medicaid Services (CMS) of the “improper payment rate” for Medicaid – pegged at 5.09% in 2022-2024, or about $31 billion per year (lower than the rate for core Medicare programs) as evidence that they can hit their cut target painlessly (the 2023 report pegged the total at $50 billion). But “Improper payment,” CMS explains, most often refers to inadequate documentation, not fraud.
New Jersey’s three Republican House members – Kean, Jeff Van Drew (R-2nd Dist.) and Chris Smith (R-4th Dist.) voted for the House budget resolution. In Van Drew and Smith’s districts, more than 20% of the population is enrolled in NJ FamilyCare, the state Medicaid program (more than 150,000 people in each district).
Van Drew and Smith have expressed some reluctance to enact severe Medicaid cuts.
Kean’s district has far fewer Medicaid enrollees – 70,000, less than 10% of the population. Kean seems willing to make the cuts – deeming them “waste, fraud and abuse” doesn’t soften the reality.
If he does so — and if Van Drew and Smith go along — they will help to take comprehensive health coverage away from hundreds of thousands of New Jerseyans.
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Andrew Sprung, a New Jersey-based freelance writer, has been writing about healthcare policy since 2007. Find his blog at xpostfactoid.
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