I have been warning for months that Medicaid would be on the chopping block if there is a second term of the Trump Administration and if Congressional Republicans win House and Senate majorities in 2025. That is because the Project 2025 blueprint, the fiscal year 2025 Republican Study Committee budget plan, and the fiscal year 2025 House budget resolution all propose draconian Medicaid cuts, with a radical centerpiece of capping and cutting federal Medicaid funding through block grants and/or per capita caps.
Now, with Republicans winning unified control of the White House and Congress, some Congressional Republican leaders are starting to speak more openly about their plans to institute deeply damaging Medicaid cuts next year. According to Politico, on November 14, Senator John Cornyn (R-TX), who finished second to Senator John Thune (R-SD) in the race for the next Senator Majority Leader, said: “We can’t just keep doing things the way we’ve been doing them…. I’m not advocating for Social Security or Medicare in the absence of a bipartisan consensus because we know that will be a futile effort. There’s a lot of other spending we should consider … We ought to look at whether we’re doing [Medicaid] the right way. Block grants make a lot of sense.” In a similar vein, on November 13, Bloomberg Government reported that House Budget Chair Jodey Arrington (R-TX) indicated he wants to use budget reconciliation to cut mandatory health spending next year. If the incoming Trump Administration holds to its campaign statements that it would not cut Medicare, this means that any major cuts would fall predominantly on Medicaid (as well as on the Children’s Health Insurance Program (CHIP) and the Affordable Care Act’s marketplace subsidies). And, on November 18th, the Washington Post confirmed that Congressional Republicans and their staff are having preliminary discussions with President-elect Trump’s economic advisors about large Medicaid cuts including federal funding caps and work requirements (as well as cuts to other programs like SNAP), which would be paired with an extension of the expiring 2017 tax cuts for high income people and corporations as part of budget reconciliation legislation next year. Then, on November 20th, the New York Times and HuffPost both reported that Congressional Republicans and the incoming Trump Administration are aiming to make severe Medicaid cuts in 2025. On November 23rd, Representative Brett Guthrie (R-KY), the current chair of the Health Subcommittee of the House Energy and Commerce Committee and a leading candidate for chair of the full committee next year, told Axios that he wants to pursue Medicaid per capita caps in budget reconciliation, similar to what was included in the failed 2017 bills to repeal the Affordable Care Act.
As this table indicates, leading conservative and Congressional Republican plans — like Project 2025, the Republican Study Committee fiscal year 2025 budget plan and this year’s House GOP budget resolution — demonstrate a firm consensus for instituting massive cuts to Medicaid, especially through block grants and per capita caps. Under the current federal-state financial partnership, the federal government pays a fixed percentage of states’ Medicaid costs, whatever those costs are. In contrast, under block grants, federal funding would be capped, with states receiving only a fixed amount of federal Medicaid funding, irrespective of states’ actual costs. Under per capita caps, states would receive only a fixed amount of federal Medicaid funding per beneficiary.
While Project 2025, the Republican Study Committee budget plan and this year’s House GOP budget resolution do not specify how the block grants and/or per capita caps would be initially set or how they would be annually adjusted, such funding caps are typically designed to fail to keep pace with expected enrollment and/or health care cost growth in order to deeply cut federal Medicaid spending over time, relative to current law. The caps would also fail to account for any unexpected cost growth either in the aggregate or on a per-beneficiary basis, such as from a recession, natural disaster, public health emergency or a new, costly drug therapy.
Moreover, as the table shows, the three plans share other deeply harmful elements. All three propose to eliminate the permanent 90 percent federal matching rate for the Affordable Care Act’s Medicaid expansion, which would shift significant costs to states and therefore force most or all states to drop their expansions over time. All three plans propose more red tape, including imposing onerous work reporting requirements, to substantially reduce enrollment among eligible individuals. The House GOP budget resolution would also block recently finalized eligibility and enrollment regulations that would increase participation among eligible individuals and families. In addition, both Project 2025 and the Republican Study Committee budget would effectively prohibit state use of provider taxes, which nearly all states use to finance a portion of the state share of Medicaid costs. Without provider taxes, states would likely be unable to even draw down all of their highly inadequate Medicaid block grant or per capita cap amounts because they will be unable to generate sufficient alternative revenues to finance their contribution to the cost of their Medicaid programs (up to the federal funding cap). The two plans would also give states new authority to drastically cut eligibility and benefits, relative to current law, which states would be certain to use in the face of federal funding cuts resulting from block granting Medicaid or instituting a per capita cap.
To compensate for the severe federal funding cuts resulting from block grants and/or per capita caps and from ending the enhanced expansion matching rate (as well as for restrictions on how states can finance their share of Medicaid costs), states will either have to dramatically raise taxes and drastically cut other parts of their budget including K-12 education or, as is far more likely, institute deep, damaging cuts to Medicaid eligibility, benefits and provider and plan payment rates. That includes not just dropping the Medicaid expansion, which covers nearly 20 million newly eligible parents and other adults, but gutting the rest of state Medicaid programs that serve tens of millions of low-income children, parents, people with disabilities and seniors.
For more analysis of the draconian Medicaid cuts proposed in each of these plans, see the following blogs:
Republican Study Committee budget plan
And for analysis of severe Medicaid cuts being proposed by other conservative groups, see the following blogs:
Center for Renewing America budget plan
Editor's Note: This blog was updated on November 23, 2024
