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Trump win could mean cuts for Medicaid

Illustration of two elephants facing a caduceus between them

Illustration: Natalie Peeples/Axios

Former President Trump this month promised not to cut Social Security and Medicare if he returns to the White House. But he notably was silent on Medicaid.

Why it matters: There's a good chance the entitlement program could face steep cuts if there's unified GOP control of the goverment, leading to coverage losses for some of the roughly 80 million low-income beneficiaries.

What they're saying: "We're not going to do anything to hurt them," Trump told Breitbart earlier this month, referring to Medicare and Social Security.

  • His campaign spokesperson did not respond when asked about Trump's designs for Medicaid.
  • "I think there's every reason to believe that Trump would look to cut Medicaid substantially if elected again," said Larry Levitt, executive vice president for health policy at KFF.

Context: As president, Trump supported a House Obamacare repeal bill that included $880 billion in cuts to Medicaid.

  • The Republican Study Committee, a major conservative group of House Republicans, released a budget this month that calls for converting Medicaid to block grants.
  • It argued the program's "costs are unsustainable" and criticized the Affordable Care Act for its spending to expand Medicaid to "healthy, able-bodied adults."
  • The Project 2025 plan from the Heritage Foundation also calls for caps on Medicaid spending.

Brian Blase, a former Trump administration health official and current president of Paragon Health Institute, called for reducing the 90% federal share of Medicaid costs for states that adopt the ACA Medicaid expansion.

  • That would ensure "the federal government's not paying more for the able-bodied expansion population than pregnant moms, kids and people with disabilities," he said.
  • That change, as well as equalizing federal Medicaid spending across states, "should be on the table and would be on the table" in a second Trump term, Blase said.
  • If Trump wins but the GOP doesn't control both houses of Congress, he could try to revive Medicaid work requirements — an effort that got bogged down in the courts in his first term.

The big picture: Medicaid enrollment swelled to record levels during COVID-19, when public health emergency rules limited states from removing people from the rolls as the pandemic raged.

  • States now are re-checking eligibility and removing millions from program rolls. The program cost roughly $800 billion in 2022.

Reality check: Obamacare's expansion of Medicaid to people with incomes up to 138% of the poverty level has become more ingrained.

  • With North Carolina's adoption last year, 40 states have now expanded their programs, and there are signs of waning GOP opposition elsewhere.
  • Trump said last fall that the GOP should "never give up" on repealing and replacing the health law. This week, he said he would instead make it "much, much better" without specifying how.

Trump's new comments came as President Biden traveled to North Carolina on Tuesday to tout his health care plans, including filling the "coverage gap" in the 10 remaining states that have not expanded Medicaid.

The bottom line: "There will be a lot of pressure under Republican control to cut spending and taxes," Levitt said. "And if Medicare and Social Security are off the table, Medicaid is the obvious place to look."

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