Consider This from NPR - Republicans say Medicaid is safe. But budget math says otherwise

Episode Date: March 10, 2025

House Republicans have to get their spending bill passed by Friday to avoid a government shutdown. They can likely afford to lose just one vote. And that's the easy part. Then they'll have to get working on their plan to extend 4.5 trillion dollars in tax cuts passed under the Trump administration — a plan that will require huge cuts in government spending. Republicans are adamant that cuts to Medicaid are a non-starter. But the non-partisan Congressional Budget Office released a report last week that said Republicans' budget likely would require cuts to Medicaid or Medicare.Learn more about sponsor message choices: podcastchoices.com/adchoicesNPR Privacy Policy

Congress is acting on one of President Trump's top domestic priorities. And the next phase of our plan to deliver the greatest economy in history is for this Congress to pass tax cuts for everybody there. But achieving that goal will require trillions of dollars in spending cuts, which will dramatically reshape the federal budget. And one big potential target for those spending cuts is Medicaid. That was Democratic Representative Al Green

disrupting President Trump's address to Congress last week. After he was removed from the chamber, he spoke with reporters. And I was making it clear to the president that he has no mandate to cut Medicaid. Now, House Republicans have said that cuts to Medicaid are totally off the table. Here's Republican Representative Tim Burchett of Tennessee

with NPR's Layla Faddle. So what I think I hear you saying is that this $880 billion of proposed cuts that people believe will hit Medicaid, you're saying it won't hurt people's coverage because that's really important to constituents. No, ma'am. Yeah, yeah. I believe that is exactly what I'm saying, ma'am.

That is exactly what I'm saying. And in politics, the Democrats- But that's a lot of money for it not to hit the actual healthcare coverage. Ma'am, it's a whole heck of a lot of money, but we're finding that over and over and over again, that there is waste, fraud, and abuse, and that's just the bottom line.

And House Speaker Mike Johnson said this last week on NBC's Meet the Press with Kristen Welker. Our cuts to Medicaid, Medicare, and Social Security off the table. Yes, and don't take my word for it, Kristen. Go do a word search of the budget resolution that we passed on Tuesday. There is not one mention of Medicare,

Medicaid or Social Security. Which is true. Those words are not in the legislation. But the reality is Republicans likely will not be able to meet their budget target without major cuts to Medicaid. That's just math. It was all laid out in a letter last week sent to lawmakers by the nonpartisan Congressional Budget Office. And with major cuts to Medicaid, the end result is... I think millions of people would lose coverage and millions of additional people would lose access to needed care as a result. That's Edwin Park, a health policy expert at Georgetown University's McCourt

School of Public Policy. He says finding $880 billion in cuts over a decade simply cannot be done without touching Medicaid. Unless you're cutting Medicare and both Speaker Johnson, other House Republican leaders and President Trump have said that they do not want to cut Medicare. So if you take Medicare off the table, Medicaid constitutes 93% of all mandatory spending that remains. Consider this. House Republicans have claimed that spending cuts will not impact Medicaid coverage. But experts say that's just impossible. We'll explain the math coming up.

From NPR, I'm Elsa Chang. This message comes from WISE, the app for doing things in other currencies. Sending or spending money abroad, hidden fees may be taking a cut. With WISE, you can convert between up to 40 currencies at the mid-market exchange rate. Visit WISE.com. TNCs apply. Support for NPR and the following message come from Bowlin Branch.

Change your sleep with Bowlin Branch's Aerie blankets, cloud-like duvets, and breathable sheets. Feel the difference with 15% off your first order at bowlinbranch.com with code NPR. Exclusion Supply, See site for details. Support for this podcast and the following message come from Dignity Memorial. In life, you plan for many important things, like weddings, retirement, and your children's education. A celebration of life is really no different.

Planning and paying for your celebration of life in advance protects your loved ones and gives you the peace of mind you deserve. It's truly one of the best gifts you can give your family. Dignity Memorial will help you take care of every detail with professionalism and compassion. For additional information, visit DignityMemorial.com. It's Consider This from NPR. Edwin Park is a health policy expert at Georgetown University's McCourt School of Public Policy, and he joined me to explain all of the math on this. Now the budget bill does not specifically mention Medicaid, but that's because the budget just gives instructions to lawmakers on the committee that oversees Medicaid to

find $880 billion in cuts over the next decade. The legislation doesn't explain exactly where lawmakers should make those cuts. So I started by asking Park very simply, can Congress find $880 billion in federal savings without cutting spending for Medicaid? It cannot unless you're cutting Medicare and both Speaker Johnson, other House Republican leaders and President Trump have said that they do not want to cut Medicare. So if you take Medicare off the table, Medicaid constitutes 93% of all mandatory spending

that remains under the jurisdiction of the Energy and Commerce Committee. Okay, well that argument has been floated, but Republicans say that they can cut spending without cutting any benefits in either Medicare or Medicaid because they're going to do this by eliminating waste and fraud. Here's another question.

Is there $880 billion worth of waste and fraud in the system? Simply no. If you look at the major Medicaid cut proposals that are under consideration, they're the same proposals that were included in the failed 2017 repeal and replace plans. And they all involve major cost shifts for the cost of Medicaid onto states because of the federal government and states sharing the cost of the program, making it harder for states to finance their share of the cost of Medicaid, or imposing more red tape on those who are already working or who aren't able to work because they're disabled, have chronic conditions, they may be caregivers or in school.

Speaker Johnson has talked about how there is about $50 billion worth of fraud in Medicaid each year. Is that an accurate estimate? I'm just curious. It is not. What he's trying to do is equate a measure that's used in the federal government to assess improper payments. But he's trying to equate these improper payments as fraud. And the vast majority of improper payments are not because the payment shouldn't have been made But there were some errors in terms of the documentation related to that payment or errors in terms of some of the Procedural steps that were taken in making those payments

But there's no finding that that was actually fraud or even payments that should not have been made. Okay. Well, one proposal that Republicans have talked about is instituting what's called a work requirement for adults who receive Medicaid, but who do not have disabilities or young children. This is actually a broadly popular idea. Like it's an idea that former Democratic Senator Joe Manchin of West Virginia had talked about in his exit interview with NPR but realistically how much would that work requirement save the federal government? According to the Congressional Budget Office it would save about a hundred and twenty billion dollars or so in federal Medicaid spending. Far cry from 880 billion. Certainly. And the reason that it produces savings is not because it encourages employment or increases

hours worked, as the Congressional Budget Office has confirmed, but it's actually about the owner's red tape in terms of reporting your employment, reporting your hours, trying to navigate a very complicated process to get an exemption because you're a person with disability or you're in school, you're a caregiver, whatever the exemption may be, this is something that applies to all states, to most non-elderly adults. And as a result, people get disenrolled. According to the Congressional Budget Office, one and a half million people would lose coverage under such a work requirement.

Okay. There's another proposal to cut Medicaid spending, and that is to reduce or eliminate healthcare provider taxes, which states use to finance their portion of Medicaid. And to be fair, there is some buy-in on this idea, like the Committee for a Responsible Federal Budget, which is a nonpartisan group focused on cutting the national debt. They call those taxes a state financing gimmick. And they say getting rid of health care provider taxes could actually save more than $600 billion. So tantalizing, is that actually a way to cut spending without cutting benefits? Actually no. All states but Alaska rely on these provider taxes to finance their share of the cost of Medicaid. And the reason such a proposal would cut federal spending, even though this is about a restriction on what states are able to do, is because

states would be unable to replace the lost revenues from these provider taxes. These are assessments on hospitals, nursing homes, other healthcare providers. They've been used under rules that have been in place since the early 1990s. And because they can't replace those revenues, they're not going to be able to maintain their current Medicaid programs. They're going to have to make cuts. So, you know, are there ways to ensure that states are in full compliance with these federal rules related to provider taxes? Certainly. But requiring blunt changes that restrict the ability of states to Continue to raise the funds they need to finance Medicaid would result in big cuts that would ultimately harm

beneficiaries whether it's losing their eligibility They're having to pay more and premiums and cost sharing they have fewer benefits covered or they can't find a provider that they need Okay. Well, I want to step back just for some perspective here. Eight hundred eighty billion dollars would be something like what an 11% cut to federal funding for Medicaid right? So like however that cut of 880 billion happens, what would it mean for Medicaid if we see more than a tenth of the federal spending on the program eliminated? I think millions of people would lose coverage and millions of additional people would lose

access to needed care as a result. It's simply the case that these cuts are large, they're significant, And many of the proposals that are being considered to achieve this $880 billion target involve shifting costs to states or making it harder for states to finance their share of the cost of Medicaid. So states are essentially left holding the bag. They're going to have to make the painful choices in terms of cutting eligibility, cutting benefits, cutting payments to providers like hospitals and nursing homes that serve Medicaid beneficiaries. And in fact, that's one of the reasons it's politically attractive to some federal policymakers

is because they're not explicitly cutting Medicaid benefits. They're making states, legislatures, governors have to make the politically difficult choices, the politically painful choices that they'll have no choice but to make in light of these massive cost shifts that they could face. Edwin Park with Georgetown University's McCourt School of Public Policy. Thank you so much for making this so clear. Thank you for having me. This episode was produced by Mallory Yoo, Connor Donovan, and Mark Rivers.

It was edited by Sarah Handel and Nadia Lancy. Our executive producer is Sammy Yenigan. It's Consider This from NPR. I'm Elsa Chang. Support for NPR comes from NPR member stations and Eric and Wendy Schmidt through the Schmidt Family Foundation, working toward a healthy, resilient, secure world for all on the web at theschmidt.org.