Comment: GOP plan to slash Medicaid is hiding in plain sight

By Matthew Yglesias / Bloomberg Opinion

Democrats say that House Republicans voted last week to enact huge cuts to Medicaid. Republicans say they did no such thing. As a matter of procedure, Republicans are telling the truth. As a question of substance, Democrats are right.

The mismatch stems from one of the many oddities of the budget reconciliation process. To delve into the weeds for just a paragraph: The Senate has 53 Republicans, which is two more than a majority, but they can’t pass much legislation because Senate rules — designed to protect the rights of the minority — require a minimum of 60 votes for most bills. There is an exception, however: If a bill is mostly about taxes and spending, it can pass with a simple majority. To consider a so-called budget reconciliation bill, the Senate and House first need to agree on a more general budget resolution. This is what the House passed last week.

The budget resolution itself does not contain any changes to tax or spending levels. Instead, it directs each congressional committee to make changes that increase or reduce the federal budget deficit. In theory, each committee is supposed to work out for itself what is supposed to happen next. In practice, of course, members don’t normally vote for a budget resolution unless they have a pretty clear idea of what leadership has in mind in terms of implementation.

So what does the House resolution call for? A lot of stuff. One instruction is for the Agriculture Committee to find $230 billion in cuts over the next 10 years. In theory, that could mean rollbacks of farm subsidies. In practice, it’s understood to mean cuts in SNAP, the federal food-assistance program. Otherwise, Republican members representing farm country wouldn’t have voted for it. Another instruction is for the Ways and Means Committee, which has jurisdiction over taxes, to increase the deficit by $4.5 trillion. That would allow Republicans to extend President Donald Trump’s 2017 tax cuts.

But back to Medicaid.

The resolution calls for “not less than $880 billion” in spending cuts over the next decade to be made by the Energy and Commerce Committee (which, despite its name, has jurisdiction over both Medicare and Medicaid). Democrats rightly point out that this means cuts to Medicaid because, mathematically speaking, the only other way to get to $880 billion is to cut Medicaid. Republicans have said over and over and over again that they are not going to cut Medicare, and for now Democrats are doing them the courtesy of believing them.

A more technically accurate way of describing the budget resolution would be to say that it “calls for” large cuts to Medicare or Medicaid, rather than simply asserting that it cuts Medicaid. The committee also oversees about $480 billion in programs that are neither Medicaid nor Medicare, but even if they were all completely eliminated — which would include the Children’s Health Insurance Program, which would have all the same political issues as cutting Medicaid — that’s still hundreds of billions of dollars short.

The TL;DR here, then, is simple: This resolution means cuts to either Medicaid, Medicare or some of both.

Republicans, as my Bloomberg Opinion colleague Mary Ellen Klas has pointed out, are likely to enact cuts that they say are not cuts. House Speaker Mike Johnson, for example, has indicated that adding work requirements to Medicaid doesn’t count as a cut. Earlier this year, House Republicans circulated a “menu” of potential spending cuts and suggested that about $120 billion per year could be saved with work requirements. But the reason this saves money is that work requirements don’t really generate much additional work. Money is saved because people leave the program, some because they refuse to comply with the terms of the work requirement and others because they simply aren’t good at dealing with the compliance paperwork.

Another likely Republican gambit is for them to say they are limiting taxes on Medicaid providers, which sounds harmless enough. Medicaid is a joint state-federal program in which the federal government matches state spending. Many states game the system to some degree by taxing Medicaid providers, then sending the revenue back to the providers. This returned revenue counts as as spending, which is then matched by the federal government.

Tightening the rules on this practice is probably technocratically sound policy. That said, it would definitely count as a cut. It would create a hole in state budgets that needs to be filled by reducing Medicaid services. Patients would suffer. And it would save about $175 billion. Even if combined with work requirements, eliminating the Child Health Insurance Program, and eliminating all non-health expenditures, the total savings would still be less than $880 billion.

Strictly speaking, Republicans are not wrong to say that last week’s vote did not cut Medicaid. But neither are Democrats to say that last week’s vote will require Medicaid cuts. There’s just no way to do what the budget resolution calls for without causing deep pain for low-income families unless Republicans are willing to go back on their repeated pledges not to touch Medicare. You don’t have to take my word for it, or that of congressional Democrats. All you have to do is look at the numbers.

Matthew Yglesias is a columnist for Bloomberg Opinion. A co-founder of and former columnist for Vox, he writes the Slow Boring blog and newsletter. He is author of “One Billion Americans.” ©2025 Bloomberg L.P., bloomberg.com/opinion. Distributed by Tribune Content Agency, LLC.