A longtime Trumpworld adviser says the party's effort to slash Medicaid is "the height of stupidity from a political perspective"
Republican lawmakers are leaving the finishing touches on President Donald Trump's "big, beautiful bill" to slash taxes for the rich and gut America's already meager safety net for the poor -- and they are working to ensure the health care cuts are sufficiently destructive and potentially damaging politically.
Under an agreement that House Speaker Mike Johnson (R-La.) and GOP leaders made to appease conservative lawmakers Sunday night, Trump's tax bill will start kicking people off Medicaid, the government health insurance program for low-income and disabled Americans, more quickly than in the previous version of the bill. That's thanks to a faster phase-in of requirements that able-bodied adults on Medicaid work or volunteer at least 80 hours a month.
"It's pretty clear that the goal here is to make an ugly bill -- the 'big, beautiful' bill that has so many ugly details -- even uglier, and to accelerate the rate at which this ugliness occurs," says Rep. Lloyd Doggett (D-Texas). He says the point of the work requirements is "creating more bureaucracy, more red tape, more excuses to deny people coverage."
Prior to the new changes, the legislation was already expected to force more than 10 million people off Medicaid. Now, the Medicaid work requirements will likely take effect in late 2026 or early 2027, instead of 2029. That means people will start losing their health insurance plans sooner -- and more people will ultimately lose their coverage over the next decade, experts tell Rolling Stone. These people will not be allowed to sign up for alternate coverage on state marketplaces, either.
"Going after fraud in Medicaid is politically popular and worth doing, but going after benefits is an attack on our own voters," says a longtime Trumpworld adviser, who adds that even if it's "defensible policy-wise, [it] is the height of stupidity from a political perspective."
The White House has publicly supported the idea of adding work requirements to Medicaid, but there are Republicans in and around the Trump administration who worry about the fallout from the House GOP's proposed changes. According to multiple sources working within and close to the administration, there's increasing internal anxiety about the potential for political backlash, including from some of Trump's base, if the final "big, beautiful" bill includes cuts to Medicaid benefits and services that are too steep.
While some of Trump's senior administration officials have long dreamed of slashing programs such as Medicaid, others in the MAGA elite believe the Republicans on Capitol Hill are intentionally leading the party in a politically "suicidal" direction -- to quote the term used so often by these professional Trumpists, including Sen. Josh Hawley (R-Mo.). These people don't know whether Trump, who likes to say he will protect Medicaid, will step in to try to limit the cuts.
The exact details of the changes negotiated by conservatives have not yet been released, so it's not clear yet whether conservative lawmakers got their wish to slash federal funding for states' Medicaid expansion populations.
The added work requirements, however, will now take effect sooner, potentially just weeks or months after the midterm elections. The point of these work requirements is not to drive people into the job market -- most people on Medicaid already work -- but to force coverage losses, experts say.
"This is framed as a work requirement, but it's really rationing health insurance coverage by complexity," says Larry Levitt, an executive vice president at the health policy research organization KFF. "It's putting administrative barriers in place that make it hard for people to get health coverage."
Anthony Wright, executive director at Families USA, tells Rolling Stone, "This bill's intent is to drown Americans in paperwork in order to make it harder to get on and stay on coverage," adding that "the savings is gained from people falling off coverage."
Levitt notes that most able-bodied adults on Medicaid already do work, so this bill "is a solution in search of a problem."
Medicaid eligibility is subject to strict income caps, which vary by state, that generally require recipients to earn exceedingly little money. States are required to conduct checks on recipients' income annually, and the consistent result is that many beneficiaries who remain technically eligible for the program lose their coverage anyway, based on administration reasons -- such as if they fail to respond to a phone call or piece of mail.
Those income eligibility checks will occur at least two times a year under the bill -- as will efforts to verify compliance with work requirements. These added administrative burdens will certainly lead to more Americans losing Medicaid coverage despite being both poor and working, and thus eligible.
"This is bureaucracy where the bureaucratic barrier is the point," says Wright.
Another complication is that many people on Medicaid cannot work but have not been approved for disability, which is an onerous process. Those people will lose coverage as a result.
Additional Medicaid cuts in the bill will slash supplemental funds going to hospitals and rural health care providers, and force Medicaid recipients to pay more health care costs out-of-pocket.
Americans who lose their Medicaid benefits due to the work requirements will not be eligible for individual health insurance plans on the marketplace, Levitt and Wright say.
In addition to the Medicaid changes, Republicans are planning to allow expanded subsidies for people on individual health insurance plans to expire -- a change that's expected to result in another four million Americans losing their insurance coverage.
Democrats estimate that Trump and Republicans' health care policies will amount to nearly 14 million Americans losing their health insurance. This would produce a roughly 50 percent spike in the uninsured rate, and more Americans would be uninsured at any time since Democrats' signature health care law, the Affordable Care Act, took effect.
Levitt says that Republicans are pushing a slate of policies that "would be the biggest rollback in federal support for health care ever, and would mean the biggest jump by far in the number of people uninsured."