Republicans Attack Medicaid

Reforms mean cuts.

Right now, Republicans in Congress are working to deliver what Donald Trump calls his “one big, beautiful bill”—a sweeping budget that slashes funding for health care, housing, education, food assistance, and climate programs in order to fund $4.5 trillion in tax cuts, mostly for the wealthiest Americans.

To pay for those tax cuts, Congress has already passed a budget framework that includes $1.2 trillion in spending cuts. Nearly $880 billion of that is targeted at Medicaid.

To deflect criticism, GOP leaders are framing these cuts as “reforms” to eliminate “fraud, waste, and abuse.” But the policies on the table aren’t reforms. They’re massive cuts—and we need to say so clearly.

In a recent interview with PBS NewsHour, Rep. Nicole Malliotakis (R-NY) offered a window into how Republicans are reframing cuts as "reforms."

Let’s be clear: every one of those “reforms” is a policy that would result in fewer people covered, fewer services delivered, and more red tape.

But first, let’s explain why Medicaid is important and who it serves.

Health Insurance for 78 Million People.

Medicaid is a public insurance program for low-income people, funded by both the federal government and the states. It covers children, pregnant people, seniors in nursing homes, and people with disabilities. Today, it provides health care to about 1 in 4 Americans— about 78 million people. At its peak during the pandemic, the program covered over 85 million people.

The number of people covered by the program grew after passage of the Affordable Care Act (ACA), which gave states the option to expand Medicaid to cover more low-income adults, especially those without children. In the 40 states (plus D.C.) that have taken advantage of this opportunity, anyone earning up to 138% of the federal poverty level (about $43,000 for a family of four) can qualify.

As an incentive, the federal government covers 90% of the costs for these enrollees, much more than the typical 57% federal match for traditional Medicaid.

But, Medicaid is more than an insurance program—it’s part of the foundation of our health care system:

• 54% of all U.S. children are covered by Medicaid or CHIP.

• 42% of all births in the U.S. are paid for by Medicaid.

• Medicaid is the primary funder of long-term care, covering 60% of nursing home residents.

• Medicaid helps fund school-based care, including speech therapy and mental health services for children.

• It keeps rural hospitals and community clinics open by reimbursing care that might otherwise go unpaid.

And no, undocumented immigrants are not exploiting the system. Federal law prohibits them from enrolling in full Medicaid. The only exception is emergency care, like labor and delivery.

What Republicans Call “Reform” Is Just a Set of Deep Cuts.

In her interview with PBS NewsHour, Rep. Nicole Malliotakis (R-NY) explained the GOP approach to “reforms” by saying:

“We’re currently discussing the expansion portion to see how we can work together to eliminate the fraud, the waste, and the abuse, to make sure that illegal immigrants are not receiving these services, to ensure that if you're able-bodied … that you have work requirements in place, and [to] cut back on some of the loopholes that the states have used to try to gain more money from the federal government.” [PBS, April 2025]

Below are the so-called “reforms” and the impact they will have on Medicaid.

Block Grants or Per Capita Caps

Instead of covering a share of what states actually spend, the federal government would give states a fixed amount, regardless of how many people need care. That means in a recession or public health emergency, funding wouldn’t increase. States would be forced to cut benefits, restrict eligibility, or reduce provider payments.

Work Requirements

These sound reasonable—until you see them in action. Most Medicaid enrollees already work, are in school, or are caring for family members. In Arkansas, when work requirements were implemented, 18,000 people lost coverage, many simply due to paperwork hurdles.

Reducing the Enhanced Match for Medicaid Expansion

The federal government currently covers 90% of the cost for expansion enrollees. If that’s cut, states will either have to slash coverage or absorb the costs, which many can’t or won’t do.

Eliminating Coverage for Adults Without Dependent Children

This would dismantle the heart of Medicaid expansion, removing coverage for millions of low-income adults, regardless of how little they earn or how badly they need care.

The “Fraud and Waste” Myth.

If this were truly about eliminating waste, the Trump Administration wouldn’t have:

• Weakened oversight of private Medicaid plans,

• Reduced staff and funding for Medicaid integrity offices,

• Shifted focus away from systemic fraud and toward minor eligibility errors.

The truth? The Medicaid improper payment rate is around 5.09%, and most of those errors are paperwork-related, not actual fraud.

There is no evidence of widespread abuse, and no serious analyst believes undocumented immigrants are driving Medicaid costs.

Medicaid impacts us all.

You don’t need to be on Medicaid to care about this. Medicaid supports your community hospital, your school nurse, your aging parent’s nursing home, and your neighbor who lost their job.

Gut it, and the whole system gets weaker.

Let’s not allow spin to disguise cruelty. These aren’t “reforms.” They’re cuts. They will hurt real people. And they’re being proposed to fund tax breaks for billionaires who need no help at all.

Sources:

• Congressional Budget Office (CBO) – Estimated cost of proposed Republican tax cuts
  https://www.cbo.gov/publication/59893

• Center on Budget and Policy Priorities (CBPP) – Republican budget framework includes $880B in Medicaid cuts
  https://www.cbpp.org/research/federal-budget/house-republican-budget-plan-cuts-essential-programs

• Centers for Medicare & Medicaid Services (CMS) – Medicaid and CHIP Enrollment Data (2024–2025)
  https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html

• Kaiser Family Foundation (KFF) – Medicaid expansion under the ACA
  https://www.kff.org/medicaid/issue-brief/status-of-medicaid-expansion-in-all-states/

• U.S. Department of Health and Human Services (HHS) – 2024 Federal Poverty Guidelines
  https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines

• KFF – Federal match rates for traditional Medicaid vs. expansion
  https://www.kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/

• Georgetown CCF – 54% of U.S. children are covered by Medicaid or CHIP
  https://ccf.georgetown.edu/2024/02/20/child-enrollment-medicaid-chip-update/

• KFF – Medicaid pays for 42% of U.S. births
  https://www.kff.org/medicaid/state-indicator/births-financed-by-medicaid/

• KFF – Medicaid covers 60% of nursing home residents
  https://www.kff.org/medicaid/issue-brief/a-look-at-nursing-facility-characteristics/

• Health Affairs – Medicaid's role in school-based services
  https://www.healthaffairs.org/do/10.1377/forefront.20190618.92610/full/

• KFF – Medicaid and undocumented immigrants: eligibility limited to emergency services
  https://www.kff.org/medicaid/fact-sheet/medicaid-and-immigrants/

• PBS NewsHour (April 2025) – Rep. Nicole Malliotakis on Medicaid reforms
  (Link will depend on transcript availability—placeholder citation)

• CBPP – How block grants and per capita caps would lead to cuts
  https://www.cbpp.org/research/health/medicaid-per-capita-cap-would-harm-millions-of-people-by-forcing-deep-cuts-and

• Kaiser Health News (KHN) – 18,000 people lost Medicaid coverage under Arkansas work requirements
  https://khn.org/news/article/arkansas-medicaid-work-requirements-trump-administration-health-care/

• Government Accountability Office (GAO) – Gaps in oversight of Medicaid managed care
  https://www.gao.gov/products/gao-21-93

• CBPP – Trump-era weakening of Medicaid integrity efforts
  https://www.cbpp.org/research/health/trumps-medicaid-policies-would-hurt-states-and-beneficiaries

• KFF – Key facts on Medicaid fraud, waste, and improper payments
  https://www.kff.org/medicaid/issue-brief/5-key-facts-about-medicaid-program-integrity-fraud-waste-abuse-and-improper-payments/

• CMS (FY2024) – Medicaid improper payment rate data
  https://www.cms.gov/newsroom/fact-sheets/2024-medicare-fee-service-payment-error-rate-and-overview

• KFF / Cato Institute – Undocumented immigrants use fewer health services than U.S. citizens
  https://www.kff.org/news-summary/study-undocumented-immigrants-use-fewer-health-care-resources-than-u-s-citizens/