Medicaid is under threat — again.
Republicans, who narrowly control Congress, are pushing proposals that could sharply cut funding to the government health insurance program for poor and disabled Americans, as a way to finance President Trump's agenda for tax cuts and border security.
Democrats, hoping to block the GOP's plans and preserve Medicaid funding, are rallying support from hospitals, governors and consumer advocates.
At stake is coverage for roughly 79 million people enrolled in Medicaid and its related Children's Health Insurance Program. So, too, is the financial health of thousands of hospitals and community health centers — and a huge revenue source to all states.
On Feb. 13, the House Budget Committee voted to seek at least $880 billion in mandatory spending cuts on programs overseen by the House Energy and Commerce Committee. That committee oversees Medicaid, which is expected to bear much of the cuts.
Senate Republicans, working on their own plan, have not proposed similar deep cuts. Sen. Ron Wyden of Oregon, the Finance Committee's top Democrat, said he expects "an effort to keep the Medicaid cuts hidden behind the curtain, but they're going to come sooner or later."
Since Trump took office, Republicans in Washington have discussed making changes to Medicaid, particularly by requiring that enrollees prove they are working. Because most enrollees already work, go to school, or serve as caregivers or have a disability, critics say such a requirement would simply add red tape to obtaining coverage, with little impact on employment.
Other GOP ideas that could gain traction toward meeting budget-cutting goals include reducing the federal government's share of costs for certain enrollees or for the program overall.
Both Trump and House Speaker Mike Johnson say they are only trying to cut what they describe as "waste, fraud, and abuse" in the program, but have yet to offer examples or specifics.
Trump has said he would "love and cherish" Medicaid along with Medicare. During a Fox News interview that aired Feb. 18, Trump repeated his assurance that Medicaid, along with Social Security and Medicare, was not "going to be touched."
Known as the workhorse of the U.S. health system, Medicaid covers Americans from the beginning of life to the end — paying for 4 in 10 births and care costs for more than 60% of nursing home residents. The program operates as a state-federal partnership, with the federal government paying most of the money and matching state funds regardless of how many people enroll.
Medicaid, which turns 60 this summer, was created as part of President Lyndon B. Johnson's "Great Society" strategy to attack poverty along with Medicare, the federal health insurance program for people 65 and older.
In today's era of extreme partisanship on Capitol Hill, few topics highlight the ideological chasm between the major political parties better than Medicaid.
Unlike Democrats who view Medicaid as a way to ensure health care is affordable and accessible regardless of income, many Republicans in Washington see Medicaid as a broken and wasteful welfare program that's grown too big and covers millions of adults who don't deserve the government assistance. Many Republicans in Congress say "able-bodied" adults could get coverage from a job or by purchasing insurance on their own.
Nearly all Republicans opposed the 2010 Affordable Care Act, which expanded Medicaid by offering coverage to millions of low-income adults and helped edge the country closer to Democrats' long-sought goal of all Americans having health coverage. In exchange for expanding Medicaid, the federal government offered states a larger funding match to cover those individuals.
But while most Republican-controlled states accepted the federal expansion dollars — some only after voters approved ballot initiatives in favor of Medicaid expansion — GOP leaders in Congress have remained steadfastly against the program's growth.
When Republicans last controlled Congress and the White House, the party sought big cuts to Medicaid as part of efforts in 2017 to repeal and replace the ACA. That campaign failed by a razor-thin margin, partly due to concerns from some congressional Republicans over how it would harm Medicaid and the private industry of health plans and hospitals that benefit from it.
Now, a more conservative GOP caucus has again put a bull's-eye on Medicaid's budget, which has grown by at least $300 billion in eight years due largely to the COVID pandemic and the decision by more states to expand Medicaid. The House budget plan seeks to free up $4.5 trillion to renew Trump's 2017 tax cuts, which expire at the end of this year.
"Medicaid is increasingly caught in the middle of partisan polarization in Washington," said Jonathan Oberlander, a health policy professor at the University of North Carolina and the editor of the Journal of Health Politics, Policy and Law. "This is not just resistance to the ACA's Medicaid expansion; it is a broader change in the politics of Medicaid that puts the program in a more precarious place."
Medicaid presents a tempting target for Republicans for several reasons beyond its sheer size, Oberlander said. "The first is fiscal arithmetic: They need Medicaid savings to help pay for the costs of extending the 2017 tax cuts," he said, noting Trump has taken off the table cuts to Medicare, Social Security and national defense — the other most costly government programs.
The GOP cuts would also help scale back the program, which covered 93 million people at its apex during the COVID pandemic, when states were prohibited for three years from terminating coverage for any enrollee. Oberlander said the cuts also would allow Republicans to strike a blow against the ACA, often called Obamacare.
Republicans' latest revamping effort comes as Medicaid expansion has become entrenched in most states — and their budgets — over the past decade. Without federal expansion dollars, states would struggle to afford coverage for low-income people on the program without raising taxes, cutting benefits or slashing spending on other programs such as education.
And since Trump's first-term effort to cut Medicaid, additional red states such as Utah, Oklahoma, Idaho and Missouri have expanded the program, helping drop the nation's uninsured rate to a record low in recent years.
Medicaid is popular. About 3 in 4 Americans view the program favorably, according to a January 2025 KFF poll. That's similar to polling from 2017.
Here are a few strategies the GOP reportedly is considering to reduce the size of Medicaid:
Cutting ACA Medicaid funding. Through Medicaid expansion, the ACA provided financing for the program to cover adults with incomes up to 138% of the federal poverty level, or $21,597 for an individual. The federal government pays 90% of the cost for adults covered through the expansion, which 40 states and Washington, D.C., have adopted. The GOP could lower that funding to the same match rate the federal government pays states for everyone else in the program, which averages about 60%.
Shifting to block or per capita grants. Either of these two proposals could lower federal funding for states to operate Medicaid while giving states more discretion over how to spend the money. Annual block grants would give states a set amount of money, regardless of the number of enrollees. Per capita grants would pay the states based on the number of enrollees in each state. Currently, the federal government matches a certain percentage of state spending each year with no cap. Limiting the federal funding would hamper Medicaid's ability to help states during difficult economic times, when demand for coverage rises with falling employment and incomes, while states also have fewer tax dollars to spend.
Adding work requirements. Republicans in Washington are looking to insert work requirements into federal law. During Trump's first term, his administration allowed several states to condition coverage for adults on whether they were working, unless they met exemptions such as caregiving or going to school. Arkansas became the first to implement the measure, leading to 18,000 people losing coverage there. Federal judges ruled in 2018 that Medicaid law does not allow for work requirements in the program, which stopped efforts by Trump and several states to impose them in his first term. Several states are taking steps to add a requirement, including Ohio and Montana.
Lawrence Jacobs, founder and director of the University of Minnesota's Center for the Study of Politics and Governance, said Republicans will face challenges within their own ranks to make major Medicaid cuts, noting that House members may be hesitant to cut Medicaid if warned it could lead to hospital closures in their district.
America's Essential Hospitals, a trade group representing safety-net hospitals that treat the disadvantaged, is encouraging its members to reach out to their lawmakers to make sure they know not only the cuts' potential impact on patients, but also how they could lead to job cuts and service reductions affecting entire communities.
"The level of cuts being discussed would be incredibly damaging and catastrophic for our hospitals," said Beth Feldpush, the group's senior vice president of policy and advocacy.
Said Jacobs: "The politics of cutting Medicaid is really quite fraught, and it's hard to make a prediction about what will happen at this point."
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF.
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