Editor’s note: This is the first in a series of stories about the effects that federal spending cuts would have on people living in the Deep South.
During an annual exam last year, doctors spotted a mass on the abdomen of Angelica McCain’s 10-year-old daughter. They were sent immediately to the emergency room, where McCain would learn her daughter had a teratoma, a rare type of tumor, on her right ovary.
“I started having a panic attack,” McCain said. “They were doing every scan and every X-ray, and all I could think about was, ‘If Avery has a disease, how am I going to pay for it?’”
Doctors surgically removed the 16-centimeter teratoma. They saved Avery’s right ovary, but she’ll be under close medical supervision for years to ensure her ovary remains healthy.
Medicaid covered the surgery. It will also pay for the annual exam and ongoing care, along with other health care Avery and McCain’s 5-year-old daughter are able to receive.
“If they didn’t have Medicaid, I wouldn’t be able to afford the annual checkups,” said McCain, a 35-year-old white woman who lives in Hoover, Alabama, and works three jobs. “We would just have to go when they are sick, and the checkups are so important. There’s no other way to say it than to say that Medicaid saved my kid’s life.”
Medicaid is the main government program covering health care insurance and long-term care to approximately 83 million people in the United States. Medicaid spending accounts for one-fifth of health care spending, more than half of spending for long-term care and a large share of state budgets, according to the Kaiser Family Foundation (KFF). States and the federal government both finance Medicaid, with the federal government paying most of the cost and states administering the program within broad federal rules. In fiscal year 2023, Medicaid spending totaled $880 billion, according to KFF, with the federal government paying 69% ($606 billion) and states paying 31% ($274 billion).
The Republican-controlled House of Representatives passed a budget resolution in late February that proposes billions of dollars in cuts that would force major changes to Medicaid. President Donald Trump and his allies have contended that Medicaid would not be cut, with House Speaker Mike Johnson saying that Medicaid, Medicare and Social Security are not mentioned in the resolution.
However, the resolution instructs the House Energy and Commerce Committee, which has jurisdiction over Medicaid spending, to make $880 billion in cuts over the next decade. The nonpartisan Congressional Budget Office released a report on the proposal indicating that the House budget does not work without cuts to Medicaid. (NPR has a closer look at why the math does not add up.)
Cuts will benefit wealthy people, corporations
The cuts would help finance $4.5 trillion in tax breaks for very wealthy people and for large corporations, extending provisions of the 2017 Tax Cuts and Jobs Act. More than half of the tax cuts would benefit the top 5% of households or those making more than $450,000 in annual income, according to an analysis from the Urban-Brookings Tax Policy Center. (The Budget Lab at Yale released a similar report with a detailed breakdown.)
The Senate’s budget resolution that was introduced in February calls for $1 billion in cuts by the Finance Committee, which has jurisdiction over Medicaid spending. In the coming months, the Senate and House will attempt to reconcile both bills to come up with a final version. (These budget resolutions would apply to future fiscal years, the next of which begins in October. The six-month funding bill Congress passed last week to avert a government shutdown is a temporary spending bill for the current fiscal year that allows the federal government to remain open while Congress negotiates its spending bills for the current year.)
10states have opted not to expand Medicaid. Alabama is one of them.
The conservative talking point that Medicaid is not being targeted in the House spending bill is inaccurate, said Theresa Lau, senior policy counsel on eradicating poverty for the Southern Poverty Law Center.
“It’s disingenuous to say, ‘We’re only going after fraud and waste,’” Lau said, referencing a popular refrain from the Trump administration that cuts are aimed at “fraud, waste and abuse.”
The belief that there is widespread Medicaid fraud is not accurate, Lau said. The reality is that Medicaid is already a very cost-efficient program with low administrative costs, she said.
“So there’s not much you can cut before it starts impacting coverage and services,” Lau said. “That magnitude of cuts will simply eliminate health care coverage for millions of people and disproportionately harm people of color.”
The SPLC released a report last week in partnership with UnidosUS and several other organizations about the devasting and disproportionate harm the proposed Medicaid cuts would have on people of color.
It’s a reality that Kiana George, a 30-year-old Black woman, is already living. George, who lives in Camden, Alabama, works as an after-school tutor. She was dropped from Medicaid in 2023 as states ended the continuous enrollment protections that were put in place during the COVID-19 pandemic. It’s left her with thousands of dollars of medical debt after she was forced to stop taking blood pressure medication she could not afford. She ended up in intensive care earlier this year with stroke-level high blood pressure.
George, like McCain, is in the Medicaid coverage gap but has a child who is covered. They both make too much money to qualify for Medicaid, but not enough to receive subsidies to help pay for health insurance through the federal marketplace. To qualify for subsidies, for example, income for a family of three must be at least 100% of the federal poverty level, which is $25,820 annually.
“What kind of sense does that make? I don’t make enough to get help, but I also make too much to get help,” George said.
The stress of being uninsured with a chronic condition and dealing with misconceptions and stereotypes people have about those who do not have insurance or who are on Medicaid can be overwhelming, George said.
“It wears you down after a while,” she said.
White people represent the single largest racial demographic of Medicaid recipients at approximately 39.5% of those ages 64 and under. McCain said she knows the stigma that Medicaid recipients face is targeted more harshly at people of color, especially Black people, whether it’s talking points from lawmakers or differing treatment from providers.
“You walk into the doctor’s office and it’s never white people on the Medicaid posters,” she said. “It’s never people with my skin color who are the face of all the negative things that are said.”
Alabama is one of 10 states that has not expanded Medicaid. Expanding Medicaid would increase the number of people eligible for Medicaid and provide additional federal funds for the program in the state.
Approximately 1 million people are currently qualified for Medicaid in Alabama, which runs one of the most restrictive programs in the country. The program primarily serves children — who make up over half of the state’s Medicaid beneficiaries — as well as people with disabilities, pregnant people, seniors and seniors in long-term care facilities. For a parent or caregiver to qualify solely based on income, they must have a child under the age of 19 and the income for a family of three cannot exceed $400 a month, for example. Adults without children are not eligible for Medicaid regardless of income.
‘We should be caring about people’
Hundreds of organizations across Alabama have urged lawmakers to reject cuts to Medicaid. Among them is the Cover Alabama coalition, which represents 130 organizations, including the SPLC. The SPLC supports Medicaid expansion and equitable access to health care primarily through federal and state policy advocacy, legal advocacy (including a class action lawsuit in Louisiana to ensure states cover Medicaid services required by law) and coalition work supported by SPLC offices in Alabama, Georgia and Mississippi.
Debbie Smith, the director of Alabama Arise’s Cover Alabama campaign, said the coalition has advocated for Medicaid expansion for years. Now faced with potential federal cuts that could jeopardize Alabama’s already lean Medicaid program, Smith said she fears the impact on those most in need of health care coverage could be significant.
“It’s the most vulnerable people in our state who have access to coverage right now,” she said.
1Mthe estimated number of people qualified for Medicaid in Alabama.
Thrive Alabama in Huntsville is a federally qualified health center that provides health care and other services — including transportation and translation — for people regardless of their ability to pay or their insured status. As a federally qualified health center, Thrive receives benefits such as a higher Medicaid reimbursement rate. Thrive Alabama CEO Mary Elizabeth Marr said recent news of Medicaid cuts has caused panic among the center’s Medicaid patients.
“I have clients calling scared asking if they still have a doctor or if they should still come to their appointments,” she said. “I have told everyone that until we are told we can’t, we will continue to take care of you. It’s very scary. I’ve been doing this for 30 years and I have never seen these kinds of obstacles. This is America. We should be caring about people.”
Jerome Dees, the SPLC’s Alabama policy director, said it is unlikely that Alabama or any other state could absorb federal cuts to Medicaid and maintain its program. Alabama is actually poised to make substantive progress on Medicaid coverage after more than a decade of delay, he said. House Bill 89, which would provide presumptive eligibility to pregnant women, is only a state Senate floor vote away from being sent to the governor’s desk for signature. Meanwhile, two bills that would cover postpartum care are beginning to pick up momentum in the Legislature.
“In light of this state’s abysmal maternal mortality rate, coincided with the looming threat of federal funding cuts, these health care protections could not come at a more desperately needed time,” Dees said.
Smith said the coalition is focusing its advocacy on communicating the consequences of cutting Medicaid to lawmakers while dispelling myths and educating lawmakers as to why measures like work requirements are unsuccessful.
“I think there’s a misconception that people who are getting Medicaid right now are leeching off the government or are not deserving of their Medicaid coverage,” Smith said. “But when we look at who the program serves, it’s children. It’s disabled people. It’s the pregnant women you claim to care about. It’s elderly people in nursing homes. And we really need our federal lawmakers to understand that.”
The gutting of Medicaid, Smith said, would not affect just those in the program.
“Our health care system as we know it will collapse,” Smith said. “I don’t think that’s an exaggeration. Medicaid is absolutely the backbone of the system. Our hospitals and clinics would not survive without it.”
Illustration at top by Katie Martin.