Editor’s Note: This article was published as part of the inaugural edition of The Commonwealth Times and reflects events as reported at the time of the referenced news coverage.
There are moments in the life of a republic when the machinery of legislative procedure — arcane, procedural, deliberately opaque — is employed to accomplish what open democratic debate might never countenance. The budget reconciliation process, that singular instrument of majoritarian will designed to circumvent the filibuster’s supermajority threshold, has become precisely such a vehicle. Congressional Republicans, emboldened by unified government and pressed by the imperatives of a tax-and-spending agenda of extraordinary ambition, have advanced proposals to reduce Medicaid expenditures by figures that range, depending on the chamber and the week, from roughly $600 billion to more than $800 billion over the coming decade. The magnitude of these numbers demands not merely scrutiny but moral reckoning.
Medicaid, enacted in 1965 alongside Medicare as Title XIX of the Social Security Act, was conceived as a joint federal-state program to furnish healthcare coverage to those whom the private insurance market had abandoned or never intended to serve. Sixty-one years later, the program covers approximately 79 million Americans — nearly one in four citizens of this republic — including low-income adults, children, pregnant women, elderly individuals, and persons with disabilities. It finances roughly 40 percent of all births in the United States. It underwrites the majority of long-term care for elderly Americans in nursing facilities. It is, by any honest accounting, the largest health insurance program in the nation, exceeding Medicare in enrollment though not in per-capita expenditure.
The reconciliation proposals now advancing through the House and Senate take several overlapping forms, each dressed in the language of fiscal stewardship and state flexibility. Chief among them are the imposition of work requirements for able-bodied adults without dependents, a mechanism that the Congressional Budget Office has repeatedly estimated would reduce enrollment far more than it would increase employment. A second pillar involves reducing the federal medical assistance percentage — the share of Medicaid costs borne by Washington — for states that accepted the Affordable Care Act’s expansion of eligibility. A third involves capping federal contributions through either per-capita caps or block grants, thereby shifting actuarial risk from the federal treasury to state governments already strained by competing obligations in education, infrastructure, and public safety.
The arithmetic is unforgiving. The CBO projected in its most recent baseline that federal Medicaid spending would total approximately $6.4 trillion over the 2026–2035 window. Proposals to extract $700 billion or more from that total — roughly eleven percent — cannot be achieved through administrative efficiency alone. They require, as a mathematical certainty, that millions of currently enrolled beneficiaries lose coverage, that provider reimbursement rates already well below those of Medicare and private insurance be further compressed, or that states assume costs they are structurally unable to bear. Most likely, all three consequences will obtain simultaneously.
Proponents of these reductions marshal arguments that deserve engagement on their merits. Federal spending as a share of gross domestic product has risen to levels that many economists regard as unsustainable, and Medicaid’s trajectory is a significant contributor. The program’s enrollment surged during the COVID-19 pandemic, when the federal government prohibited states from disenrolling beneficiaries as a condition of enhanced federal matching funds, and the unwinding of that continuous enrollment provision has been fraught with administrative error and bureaucratic dysfunction. There are, indisputably, individuals enrolled in Medicaid who no longer meet eligibility criteria. The question is whether the legislative sledgehammer of reconciliation is the appropriate instrument for what ought to be a scalpel’s work.
The work requirement provisions reveal the ideological architecture beneath the fiscal scaffolding. Arkansas, the first state to implement Medicaid work requirements under a Section 1115 waiver during the first Trump administration, saw more than 18,000 beneficiaries lose coverage in the six months before a federal judge struck down the policy. Research published in the New England Journal of Medicine found that the requirements did not increase employment but did increase the uninsured rate among low-income adults. The reasons were not mysterious: the administrative burden of documenting work hours or qualifying exemptions proved an insurmountable obstacle for populations contending with unstable housing, unreliable internet access, and the very health conditions that Medicaid was designed to address.
The proposed reduction in the federal matching rate for expansion populations strikes at the structural incentive that persuaded forty states and the District of Columbia to extend Medicaid eligibility to adults earning up to 138 percent of the federal poverty level. The ACA offered a 90 percent federal match for this population, compared to the traditional range of 50 to 77 percent for other eligibility categories. Reducing the expansion match to traditional levels would impose billions in new costs on state budgets. Governors of both parties have warned, with varying degrees of public candor, that such a change would compel them to terminate expansion coverage entirely, disenrolling millions of adults who gained insurance for the first time in their lives during the previous decade.
The human topography of these proposals is not abstract. Medicaid covers 40 percent of all children in the United States. It pays for the care of two-thirds of nursing home residents. It is the nation’s primary payer for mental health services and substance use disorder treatment — this last fact carrying particular weight in states ravaged by the opioid and fentanyl crises, where Medicaid-funded treatment programs represent the thin membrane between recovery and catastrophe. Rural hospitals, already closing at a rate that constitutes a deepening challenge in American healthcare infrastructure, derive a disproportionate share of their revenue from Medicaid reimbursement. To further constrict that revenue stream is to hasten the disappearance of emergency and inpatient care from communities that have no alternative.
The political dynamics are no less consequential than the policy substance. Republican members from districts and states where Medicaid enrollment is highest face a calculus of excruciating precision. The ten states with the highest Medicaid enrollment as a share of their populations include West Virginia, New Mexico, Louisiana, Kentucky, and Arkansas — states that delivered decisive margins for Republican candidates in recent federal elections. The voters who would be most directly affected by coverage losses are, in many cases, the same voters whose economic anxieties and cultural grievances the Republican coalition has successfully channeled into electoral dominance. Whether those voters will perceive the connection between a reconciliation vote in March and a coverage termination letter arriving in their mailbox eighteen months hence is the operative political question.
The reconciliation process itself merits scrutiny as a matter of democratic hygiene. The Byrd Rule, which constrains reconciliation measures to provisions with budgetary impact, was designed to prevent the procedure from becoming a vehicle for sweeping policy changes unrelated to taxing and spending. Yet the transformation of Medicaid’s eligibility structure, the imposition of behavioral conditions on the receipt of public benefits, and the fundamental reallocation of fiscal responsibility between federal and state governments are policy determinations of the first order. That they are being advanced through a procedure requiring only a simple majority in the Senate, with limited debate and no possibility of filibuster, ought to trouble citizens regardless of their substantive views on the merits.
There is, moreover, a profound irony in the conjunction of Medicaid reductions with the reconciliation package’s other principal objective: the extension and expansion of tax provisions enacted in 2017, whose benefits accrued disproportionately to corporations and high-income households. The Tax Policy Center estimated that the 2017 Tax Cuts and Jobs Act reduced federal revenue by approximately $1.9 trillion over its first decade. To finance the perpetuation of those reductions by diminishing healthcare coverage for the poorest Americans is to execute a transfer of resources from the bottom of the income distribution to the top — a policy choice that may be defended on economic grounds but should not be disguised as deficit reduction.
The framers of this republic understood that the legitimacy of government rests upon its capacity to promote the general welfare — a phrase they inscribed in the Preamble not as aspiration but as obligation. Medicaid, for all its imperfections, for all the genuine inefficiencies and perverse incentives embedded in its sprawling structure, represents an expression of that obligation. To reform it is the work of responsible governance. To eviscerate it through a process designed to circumvent deliberation is something else entirely. The Congress now deliberating these proposals would do well to recall that the measure of a civilization is not the comfort it affords those who need no assistance, but the dignity it extends to those who do.