Bulwark Takes - Trump Country Is About to Get Hosed By GOP Lawmakers

Episode Date: May 7, 2025

Sam Stein and Jonathan Cohn break down the Republicans’ proposed Medicaid cuts with the potential impacts on millions and political blowback for the GOP.  Read More, "Laura Loomer Just Called the GOP’s Bluff on Medicaid Cuts"

Hey guys, it's me, Sam Stein, Managing Editor at The Bork, and I am joined by our senior Laura Loomer correspondent, Jonathan Cohn, who happens to also write about policy for us, but his latest newsletter, The Breakdown, did cover Laura Loomer, and it was for a real reason. She has weighed into the Medicaid debates in a surprising fashion. All right, Cohn, what is the state of play with the Medicaid cuts here and how House Republicans are structuring what is essentially the only real major piece of legislation that they're going to be considering this year? Yeah, well, the state of play is I'm writing about Laura Loomer, which is not something I signed up to do. I thought we hired Will Sommer for that, but apparently it's not enough. I actually had to ask Will Sommer.

I'm like, can you give me like how do I sum up Laura Loomer in a sentence? So I'm really glad you did hire. Well, one day he's going to pay it back and you're going to have to describe how to, you know, talk about Medicaid policy to him for a newsletter. But we'll see. All right. What's the state of play on this substantive stuff here? Right, right. So the big picture, right?

They want to pass a tax cut. They're trying to pay for part of the cost by cutting Medicaid. Big argument in the Republican Party. You have the Medicaid cutters, people, you know, historically, this program's too big. We don't look like it. We want to downsize it, shift more responsibility onto the states. We want up to, you know, $800, $900 billion in cuts. Billion. With a B. Billion. With a B. Yes. And that's over 10 years but that's a you know as we like to say your money even in washington yeah so that's the uh that's the sort

of push and you know uh on the flip side you have moderates and not just moderates it's not even so much about ideology but it's it's it's senators and house members in particular because right now we're in the house who are like, wait a minute, got a lot of people in my district on Medicaid, a lot more than it used to have because we've expanded it. If those people lose it, that's going to be a problem. Just to be clear, the expansion, it's also coincided with these interesting political coalition changes that

have seen many more rural rights go into Republican camps here. Like these are the Trump voters who are on Medicaid. And Republicans are like, wait a second, we just recruited these people into our political coalition and now we're going to rip apart their health care. It doesn't make much sense. Yeah. Yeah. And I'll just give you sort of two examples of how that plays off in real life.

So, I mean, Medicaid is a huge huge huge financier of substance abuse treatment so if you think about put think of a map where the opioid epidemic was most severe right where are you talking about appalachia west virginia and you got a ton of people in west virginia on medicaid it's paying for their opioid treatment uh and then you know medicaid has become this huge payer of maternity care, especially in the South where just because of the low income there, you have so many people who qualify for it. And so if you are taking a big chunk out of Medicaid, you're affecting a lot of people who are part of the Republican coalition now. And by the way, not just the people getting health care, right? It's jobs. It's hospitals. It's providers. Hospitals in rural places. Yeah.

All right. Let's get wonky here. So Dave Dayen, great journalist, obtained a list of proposals that are under consideration for reforming and cutting Medicaid. You've seen other reporting out there in terms of what's on and what's off the table. Give us a rundown of where we stand in terms of the proposals that are in and that are out. Yeah, yes, that's a Dave, Dan, at the American prospect got what looks like the current list. And you know, it's in flux. And this is, you know, it's gonna be constantly changing. The big ticket items that you see, I'm looking to make sure I got his list, right, it just came out. One of the big ones is sort of more frequent checks of eligibility. That's a big deal, Sort of, you know, rather than having to establish your eligibility every few months, that is sort of adds a lot of paperwork. And we know from experience that if you do that, what ends up happening, these systems are hard to use. People on Medicaid,

so many of them are like seasonal jobs, you know, it's hard to get the documentation right. Sometimes they, you know, the online systems, these states run, they're underfunded, they break down, and you end up lots of people getting kicked off the program, even though they're eligible. So, you know, people lose insurance. It just increases the charge. They just don't do the paperwork in time. They lose it. They file it improperly. And then, yeah, you'll catch some people who may not be eligible. More likely than not, you'll see a reduction in forces through attrition. Yeah. Yeah.

And look, I mean, the people who argue for this, their whole argument is there's people on Medicaid who aren't eligible anymore. We need to catch them. You will root those people out, but at a cost of kicking off tons of people. All right. So that's one, that's one that's under consideration. What else? We are seeing, according to this reporting, a sort of introducing sort of cost sharing or premiums for people who are on Medicaid and above the poverty line. So, you know,

right now, one of the things that happened with Affordable Care Act was they expanded Medicaid enough so that even if you had income slightly above the poverty line, it isn't a lot of money, you know, $40,000, something for a family of, you know three you could still get medicaid in recognition the fact that these are people again working in low-wage jobs multiple part-time jobs can't even afford you know even if their job does offer coverage they can't afford premiums so putting them on medicaid is a way to get them healthcare these are very low-income people we know for a fact they really can't afford you know to pay premiums or out-of-pocket costs in a way that people higher income.

So again, it's another way of sort of cutting healthcare for low-income people in a way that doesn't look maybe you can sort of sell as not a cut or as like a kinder cut. Okay, kinder cut. It's a little bit more blunt than the other proposal, but go ahead. Yeah. All right. It does sound like they are going to add work requirements, and that is not surprising. This is something that's been talked about from day one.

So just general gist of it. You have to prove that you're looking for work or have tried to obtain work. What is the actual requirement here? So again, we haven't seen the details, but we've seen these before. Typically, you have to demonstrate that you either have a job or they typically will have some categories like, you know, if you're in school, you have a disability, you can demonstrate you have on caregiving response sometime. But, you know, we don't know what the exceptions are. But more important, this is this is just like what we were talking about before. We've experimented with these before. What always happens is it's hard to report. It's

hard to verify. People get caught up in the wash and millions of people lose health insurance as a result. And most of them are people who, when you dig into it, actually, they were still qualified for the program. They just couldn't, you know, they just couldn't verify it. And then there's one other category that seems to be in there, which is about these provider taxes, which is basically- Yeah, tell me about that. You know, it's a complicated- I was trying, which is about these provider taxes, which is basically about that. You know, it's a complicated, I was trying, I was actually trying to read up on it before this video. And I was

like, what you're providing, you're taxing the providers in the States to fund the state match to the Medicaid. I just blew my mind. So there's a really good story that was in New York times a couple of days ago. We want to look at that by margo sanger katz and sarah cliff two great reporters that sort of detailing this but basically because the way medicaid works with the federal government matching what states you know providing funds you know most of the funds but there's a formula which is based in part on what the states spend and states basically a long time ago figured out well we can kind of come up with what sort of is, I would describe almost as a legal kickback scheme where they basically tax, you know, like the hospital, they say, you hospital, we're going to tax you, but then that's okay. Because,

because we're going to then spend more money, we're going to get more money down from the federal government. And so you will sort of basically won't have to pay more. It's, I'm sort of simplifying for the sake of doing this without charging. No, no, it's helpful. It really is really helpful. You know, and, you know, people look at this and say, okay, states are gaming the system. And that's fair. I think that's a fair description of what's happening. On the other hand, the entire health care system is like sort of these convoluted arrangements that have been built one on top of the other. And in effect, it's a way to get more federal money into the Medicaid system.

Gotcha. top of the other. And in effect, it's a way to get more federal money into the Medicaid system. And so, you know, you can argue it's not the way the system was designed. You can argue there are lots of states taking advantage of it. On the other hand, pretty much all the states now, except Alaska, take advantage of it through this scheme. Alaska, get on it. What are you doing? We could do a whole show on healthcare in Alaska. I'm sure the numbers will be incredible on YouTube on that one. Let's quickly move to the, because there's another thing that came out here. So that's the general, I want to just say there are some other proposals that I've read about.

They want to be sort of blunt in terms of the matching rate on expansion. They're talking about spending caps on enrollees. We can get to that in a second because there was another big development today, which was the CBO, the Congressional Budget Office, responded to a Democratic lawmaker letter asking for assessments on what the losses in coverage would be if you were to implement some of these proposals. And the numbers were pretty stark. I mean, we're talking about in the millions of people who would lose their health care

coverage here. What is the sort of top line takeaways that you had from that? Yeah. So, you know, the Democratic leaders in the House and Senate asked the Congressional Budget Office, they sort of took the biggest items that were under discussion at the time, some of which look like are definitely ending up in the bill, some of which may not, again, a fluid negotiation who knows where this will be in two weeks, two months. What the CBL found was in one hand, yeah, if you do make these changes, you can save a lot of money. You can get hundreds of billions of dollars, which again, is what Republicans are trying to do. Oh, but by the way, millions of people are going to lose health insurance. And typically what happens is a ton of people end up losing Medicaid coverage. Some of them find their way to other coverage,

and typically it ends up that they're getting, you know, sort of subsidized private insurance through the Affordable Care Act, healthcare.gov. But a lot of people end up uninsured. So just to give you two examples here. So we were talking before about this change in this sort of provider rates. We were just speaking a minute ago. So CBO says, if you make this change, again, based on the details they were provided, you know, that you can save, you know, looks like more than $400 billion, the federal government could save, you know, up to more than $400 billion that way. But almost 9 million people lose Medicaid coverage, and about half of them are a little less than half of four, almost 4 million end up uninsured. So you know, yeah, you know, and about half of them, or a little less than half, so almost 4 million,

end up uninsured. So yeah, and then that's sort of for any of these changes. I mean, we could get- Right, that's the trade-off. That's the trade-off. Less money, less insured. That is the trade-off here. All right, let's step back for a second. How big a bind do you think the people writing this bill, specifically this portion of the bill, and leadership on the Republican side is as these things start to come into focus? I ask that because up until now, they've been kind of kicking the can down the road. It's like, look, we're going to fill in the details, just pass the budget framework. We're going to kick it back and forth from the Senate, and we're going to listen to the moderates. And they're ruling these things out. They're not ruling these things out. And eventually, you have to deal with hard numbers

and legislative language. And we're kind of reaching that point now. So how big a bind do you think they're in? I mean, it's a big bind. They have two very opposed views. I mean, on the one hand, there's the sort of push to cut spending, reduce government, because these are conservatives. They think that's the right thing to do. They want it to offset the cost of push to cut spending, reduce government because these are conservatives. They think that's the right thing to do. They want it to offset the cost of their tax cut, which that is the one thing. They are going to do a tax cut because what Republicans do. It's not a tax cut. You keep calling it a tax cut, but it's an extension of a tax cut.

Am I missing something? I mean, obviously, they're budgeting it in a certain way, but they want to extend expiring tax cuts. People will not feel it as a tax cut. They'll feel it as an extension of the rates. Right. Although they're also talking about, remember, they want to add- Oh, no tax on tips, no tax on Social Security. Fine.

If they can get those in. If they can get all those. And obviously, how much they get depends on how much they can offset. So that's all pushing them. That's momentum in the direction of, let's make these big spending cuts. But now, we were talking before, these are real cuts that are going to affect real districts. They're going to feel that.

They're going to feel it. I'm reminded, so this has got me thinking, I'm trying to think of the parallels, but the best parallel in recent memory is ACA repeal. In the ACA repeal, we hit a point where suddenly the CBO score started coming in and they were like, oh, wait, we're talking like millions of people

losing their coverage on the exchanges or through various other means. Wait, you're going to really take out some of these, you know, how are you going to mess with preexisting conditions, the protections in that law? And then it got a little dicey. And then they were like the house, Paul Ryan and the house were like, don't worry, you pass this bill, but we're not going to actually implement this bill. We just need to keep the process going. And so that was, and at some point, and it was with the Senate, then said, no, we're not going to do this, McCain specifically. At some point, McCain was like, no, we're not going to like have a leap of faith that we will just get this all done in the joint committee. So I don't think we're at that point yet.

But I just want to read this quote from Don Bacon, who was a congressman from Omaha, maybe one of like a handful of moderates in the Republican caucus. He says this, and this is to Wall Street Journal. Here's the tactic they're using. Don't worry about the Senate. They'll fix it. And now we're getting ready to take our third vote on this. We feel like we're being pushed up to the edge of the cliff here. And to me, that's Bacon basically channeling what people

felt like in the ACA repeal debate, which is you're asking us to take a leap of faith that things will get sorted out in the end and all will be well. But eventually it's like you just can't sort it out. Reality steps in. Yeah. Look, that trust or lack thereof between the two chambers is a hugely important factor whenever these things come up. I think memories of what happened last time when you had a bunch of House Republicans who voted for repeal, only to have repeal die in the Senate and feel like, I got burned. That's one more reason if you're Don Bacon in a vulnerable district or someone wavering on this, you think, you know, you're being asked, you're being pushed to take taking this vote. And then, you know, you're going to get burned for it. Now you and I remember,

do you remember BTU? Do you remember that phrase? You know, from the Clinton? Maybe it's just me. No, I do not. I do. I was going to, I was thinking of cap and trade from the Obama years when the house had to vote on that and they never went anywhere in the Senate. Perfectly good example. The predecessor to that, oh, God, I feel so old. So the Clinton, this is very famous, first year of Bill Clinton's presidency, they pushed through a similar kind of thing, a carbon tax. It was called a BTU tax.

I don't remember what BTU stands for. Something unit. Sure. And they got, I think it was, did they get, I think they got it through the House, and then the Senate killed it. And they had all these House Democrats who now had to carry around this vote that got, that was like an albatross and it hurt them in 94. So this trust is always there. And you know, look, they may overcome one of the reasons they were able to get over the line on the ACA was because throughout the process and years before the process, they built up a really good working relationship between the Senate leaders.

Well, this gets us to another place. And we're going to talk about this at some point. The reason that the ACA did work is precisely because you had committee chairs who were working on this stuff and who knew other committee chairs and the House and the Senate, even though they had somewhat divergent views on how to do this, ultimately they are able to sort of talk to each other and reconcile it. And when you push out seniority, when you get rid of those people, when you don't actually work through committee, this becomes a little bit, if not a lot harder. So yeah.

All right. We're going to leave it there, but we're going to check back in repeatedly on this idea because this is the biggest policy issue going right now. Maybe one of the only big ones going right now. And we're fortunate enough to have Cohen on top of it and on top of Laura Loomer and her tweets as well. It's a double whammy. You're really pulling double duty here. Maybe we can get rid of old summer. We got you. All right. Thank you, buddy. Really appreciate it.