With expected deep cuts to Medicaid looming over Americans who rely on the program, advocates say that the entrenchment of the program across both Democratic and Republican-leaning states has left Republicans vulnerable to pressure from a public that overwhelmingly opposes cuts and which could potentially sway some in the GOP conference.
Kerry Adelmann, an SEIU member and home care worker, told Salon that, in her experience, “people are terrified” about the anticipated cuts to Medicaid. What makes it worse is the uncertainty over what exactly may be slashed in the GOP's quest to cut some $880 million in federal spending, a sum that experts say would almost certainly require reduction in Medicaid funding.
“Anytime you’re doing any kind of check-in, people are like, ‘I'm afraid,’” Adelmann said. “I keep going to the internet. Everybody’s trying to brace themselves for what it might mean. How could they take that big of a cut and have it not affect us in some way?”
In addition to her job, Adelman is one of the millions of Americans who rely on Medicaid herself. Her son was injured in an accident in 2015 and was left unable to work. Without Medicaid, she said their family wouldn’t be able to pay for the care he needs or even the basics, like a wheelchair or access to a handicap-accessible van.
Last month, congressional Republicans passed a budget blueprint that calls for $880 billion in cuts from programs managed by the House Energy and Commerce Committee, with Medicaid being far and away the biggest budget item on the chopping block. That has left Americans like Adelmann anxious as they await further details on the Republicans' plans for Medicaid. Republicans, meanwhile, have fanned out across the country to promise that they won’t cut Medicaid benefits, despite their agreement to cut hundreds of billions of dollars.
GOP promises not to cut benefits, combined with their promise to find $880 billion in savings for the federal government, has led analysts to suspect that the party may be eyeing a change to federal funding for Medicaid expansion. This would allow Republicans to technically not directly cut Medicaid benefits, instead pushing the hard decisions on what benefits to cut to the states. Reporting in Axios and The New York Times has validated this theory.
“I think it's time that we reform [the] entitlement program, particularly in the expansion area,” Rep. Brett Guthrie, R-Ky., chair of the House Energy and Commerce Committee, told Axios.
Edwin Park, a research professor at the Center for Children and Families at Georgetown University, told Salon that there are several approaches the House GOP could take. One is a per capita maximum on federal Medicaid funding for the states, which would mean capping the amount the federal government will spend per beneficiary in each state. Another avenue is eliminating the current matching rate for Medicaid expansion under the Affordable Care Act. Currently, the federal matching rate is 90%, meaning that the federal government pays 90% of the costs for Medicaid expansion enrollees.
“If you have those kinds of proposals with states having to balance their budget, unlike the federal government, states either have to kick in a lot more of their own funding through higher income taxes, sales tax or other taxes,” Park said. “Or you have to cut other parts of their budget, principally education. Or, they're gonna have to make big cuts to the Medicaid program. If they do make cuts there's eligibility, there's benefits, and there is provider payment rates and Medicaid payments.”
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In real terms, a per capita cap on federal spending on Medicaid would shift around $532 billion of cost from the federal government to the states over 10 years, according to one KFF model. Likewise, changing the federal mapping rate could shift $626 billion in costs from the federal government to the states, according to another KFF model.
Both of these scenarios, however, assume that states would maintain their current Medicaid expansion programs as is; this isn’t likely to be the case. While 41 states have a Medicaid expansion program, nine states — Montana, Utah, Arizona, Arkansas, Illinois, Indiana, Virginia, North Carolina and New Hampshire — have trigger laws that would end their Medicaid expansion programs if there is any reduction in federal funding.
Ted Ruger, a University of Penn Carey Law professor focusing on health law, told Salon that in practical terms this means states, which don’t have the same budgetary resources as the federal government, will have to make decisions about who to cut off the Medicaid rolls and how to cut reimbursement rates for doctor and hospitals.
“It's estimated that a state like Pennsylvania, which has a big healthcare industry, is going to lose over $2 billion a year in just lost payments to providers and such. So it's a big deal and a big problem, and there doesn't seem to be any plan to how to make up the deficits,” Ruger said.
Robin Rudowitz, the vice president at KFF and director of the Program on Medicaid and the Uninsured, told Salon that if national Republicans put states in this position the states “don't have great options.”
“States largely need to balance their budgets each year, and they could either make up the lost federal dollars. So that would mean cutting other parts of their program or raising revenue. Both of those are difficult decisions. States don't like to increase taxes, and the largest piece of state funding for their budgets is education,” Rudowitz said. “The other piece is that they can look to reduce spending on Medicaid. The levers there are reducing coverage, reducing provider rates or reducing services and access.”
Rudowtiz added that, when you look at the breakdown of who enrollees are, about half are qualified adults and children “but over half of the spending on the program is for people who qualify on the basis of age or disability.”
Beyond just the direct enrollees, Rudowitz said, many community health centers, especially in rural areas, are financially dependent on Medicaid and Medicaid expansion. A big reduction in funding could undermine the financial feasibility of healthcare centers in these communities.
Kelly Hall, executive director of the Fairness Project, a union-back advocacy group that campaigns for progressive ballot initiatives, told Salon that even though the situation looks dire, the fact that 41 states have made Medicaid expansion a key part of their healthcare system gives residents there a way to fight back.
Hall pointed to Sen. Josh Hawley, R-Mo., as an example of a Republican who has been forced to support Medicaid expansion over time. As attorney general of Missouri, Hawley fought to have the Affordable Care Act ruled unconstitutional. In 2025, however, he was one of the first Republicans to come out against Medicaid cuts.
While one Republican senator saying that they don’t want to cut Medicaid won’t be enough to sink the GOP budget, which only requires a simple majority in the Senate, Hall said that his movement on the issue is instructive.
“To me, the key thing that I'm paying attention to and happy to talk about is what: What is changing the minds and the calculus for these Republicans, not just in swing districts, but also in safe seats like Josh Hawley's, who are suddenly realizing the implications of cutting Medicaid, both for their constituents and also in the case of Missouri, their state budget?” Hall said. “Medicaid expansion is in the state constitution there they cannot easily undo Medicaid expansion, even if federal funding declines, and so it's really just a cost shift to the state, and that is a really different dynamic than we had when people were previously trying to repeal or a gut Medicaid expansion in the first Trump administration.”
Hall went on to note that other states, like South Dakota and Oklahoma, directly inserted Medicaid expansion into their state constitution, meaning that the GOP budget at the national level could have disastrous effects back home.
Sen. Mike Rounds, R-S.D., for example, has been arguing against some of the proposals to shift Medicaid costs to the states.
“That’s not a cost cutting measure — that’s a cost transfer,” Rounds told Politico. “And when you’ve got partnerships with the states, you shouldn’t be doing that without having them involved in the discussion.”
Hall explained that this sort of political exposure for Republicans is a secondary effect of efforts to expand Medicaid across the United States. She said that “expanding Medicaid anywhere helps protect Medicaid everywhere, and that's what we're seeing play out right now.”
“The program has expanded radically across the country, so that there are so many people in red districts, in red states that also have something to lose if a chainsaw is taken to the Medicaid budget. That doesn't just help people in those red states. Having a broader political constituency that cares about Medicaid protects it everywhere,” Hall said.
It’s clear too, that there is a broad constituency for preventing cuts to Medicaid expansion across party lines. A recent KFF survey found that, even among Republicans, 67% of respondents wanted to see Congress either increase Medicaid spending or keep it about the same. Among rural Republicans, this number was 65%.
In terms of the federal matching rate for Medicaid expansion, 59% opposed any reduction in the federal government's contribution, including 65% of independents and 35% of Republicans.
In Hall’s opinion, this majority coalition is the sort of force that can put the breaks on the GOP’s budget plan, especially if advocates are able to effectively communicate how “The ripple effects of Medicaid being cut or Medicaid expansion being repealed will extend way beyond the people who actually are enrolled in the program.”
When asked whether she's observed the sort of political consciousness needed to fight back against these cuts yet, Adelmann, the home care worker whose family relies on Medicaid, told Salon that in her experience with patients and other workers, told Salon that "I don't know if its that evolved." What she did say, however, is that there seems to be an appetite for information about these cuts and for organizing against them: "People like me are asking questions like 'who can I talk to?'”
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