Congress Needs to Cut Medicaid, Even More Drastically Than in the "Big, Beautiful Bill"

Congress has made its way into the news cycle as the House passed the "Big Beautiful Bill" (HR 1). There has been criticism of how this Bill would exacerbate the deficit, between there being tax cuts and spending increasing. I can understand that argument. When you lower revenue while increasing spending, that increases the deficit run. When a government continuously spends more than it has, it creates debt. That is basic accounting. At the same time, what I brought up last year is that the permanent income tax cuts are not the root issue, but rather exorbitant government spending. This much was made clear when the credit rating agency Moody's downgraded the U.S.' credit rating earlier this month. 

One of the more notable spending cuts in the "Big Beautiful Bill" is with regards to Medicaid. Founded in 1965, Medicaid is the U.S. government's program that helps cover healthcare costs for low-income individuals, typically under 65. Medicare, on the other hand, covers healthcare for individuals over 65. Medicaid currently covers 71 million Americans, which is about a fifth of the overall U.S. population and 40 percent of the U.S. children population. 

The Bill is proposing a number of changes to Medicaid, including: imposing work requirements for able-bodied adults without dependents (I analyzed the requirements before for SNAP); increasing eligibility checks to twice a year; lowering the federal match for states that provide Medicaid to undocumented immigrants; cost-sharing for expansion enrollees; and banning new or increased provider taxes used to draw federal funds. The reason why these reforms are causing such consternation is because the Congressional Budget Office (CBO) estimates that the bill a) will cut Medicaid by $698 billion over the next decade, and b) at least 8.6 million people will lose Medicaid coverage by 2034. 

Medicaid proponents treat Medicaid as a sacred cow and look at critics or opponents as cold-hearted bastards who do not care about the poor. The Left-leaning outlet Vox saw the Republican's move as the "cruelest cut in the Republican budget bill." I saw the numbers and thought that the Republicans are not going nearly far enough, especially given that the Republican's bill is not actual spending cuts but modestly curbing cost growth. Here are some realities around Medicaid that we have to contend with:

1. Medicaid spending is not fiscally sustainable. Medicaid spending was $118 billion in 2000, was $557 billion in 2024, and is projected to be $898 billion in 2034. Outside of interest payments, the major government program with the fastest spending growth is Medicaid. Balancing the federal budget without touching healthcare would require a 40 percent cut in other government spending. 

2. High improper payment rates. According to the Centers for Medicare and Medicaid Services (CMS), there was a 5.09 percent improper payment rate in 2024. That may sound small to some, until you realize that means $31.1 billion of improper payments in 2024. Because CMS ignores eligibility checks (which are the biggest source of error), there effectively has been over a trillion dollars (yes, that is trillion with a "t") spent in improper Medicaid payments over the past decade. If you do not think it is that bad, you can read this 2024 testimony from HHS' Office of Inspector General or this 2024 report from the Government Accountability Office (GAO) showing the extent of the problem. 

3. Medicaid does not help save lives. I wrote on this topic in 2017 because a major component of Obamacare was the Medicaid expansion. 2017 was a time when the Republicans were trying to repeal Obamacare and the Democrats were falsely clamoring about how repealing Obamacare would have killed thousands.

I know that a National Bureau of Economic Research (NBER) was released earlier this month finding that Medicaid expansion saved lives. However, it is methodologically flawed in that it used a "difference in difference" framework. What this means is that the NBER study assumed that difference in outcomes by state was entirely due to Medicaid expansion, which is specious to say the least. RCTs have better causal inference because it eliminates selection bias, has stronger internal validity, and has flexibility in measuring multiple outcomes.That is why I prefer to go to randomized control trials (RCT), which are the gold standard with this sort of research. 

As far as RCTs in this topic go, there is the Oregon Medicaid expansion RCT, which showed that Medicaid expansion did not have statistically significant impact on health outcomes (Baicker et al., 2013). Then there is the RAND Health Insurance Experiment. While it was conducted from 1971 to 1986, this RCT remains to this day to have been the largest U.S. public health study conducted. The RAND study found that cost sharing led to reduced healthcare utilization without affecting outcomes. A working paper from the Mercatus Center similarly shows that Medicaid expansion failed at improving the health outcomes of lower-income adults (Sigaud and Bjoerkheim, 2024). I also wrote last December about how those states that took on ACA Medicaid expansion actually fared worse in terms of life expectancy than those who did not. 

Postscript. As much as I would like government out of healthcare, I do not expect Medicaid to disappear. After all, 71 percent of Trump voters oppose Medicaid cuts. Even so, eliminating the fraud and waste would be a welcomed step in the right direction if there is any chance for Medicaid to have a future. Here are a few ideas that Congress ought to consider:

• Eliminate or lower Medicaid expansion federal match rate. States that implemented Obamacare expansion receive a 90 percent federal match (FMAP) for adults covered under the expansion. The Kaiser Family Foundation (KFF) calculated that removing this FMAP entirely would save Medicaid $1.9 trillion over the next decade, as well as reduce enrollment by 20 million. 
• Penn State's school of health economics argues that a 50 percent federal match floor would be a more measured approach that would still save $530 billion over the next decade without being too burdensome. 
• Eliminate provider taxes. As the Cato Institute points out, provider taxes create the perverse incentive of shifting the costs to the federal government. The "Big, Beautiful Bill" only stops new provider taxes from being created. The CBO found that eliminating the provider taxes would save $612 billion over the next decade. 
• Convert Medicaid into block grant program. This option would provide a capped amount of funding versus open-ended funding based on actual spending. The bipartisan Committee for a Responsible Federal Budget (CRFB) estimates that limiting growth of payments to the level of inflation would save $950 billion over the next decade.
• Reduce supplemental payments. Supplemental payments drive up Medicaid costs by enabling states to inflate total Medicaid expenditures without corresponding increases in care quality or availability, often through financing schemes. You can read the CRFB's primer on supplemental payments here, but essentially, reforming finance law to reduce these supplemental payments would save $500 billion over the next decade (CRFB). 

This piece is not meant to be a treatise on Medicaid reform or to provide a pro/con list of each potential reform, but rather to illustrate how inefficient Medicaid is, how badly it needs spending cuts, and how there is no shortage of policy alternatives. If you are interested in more reforms that would not particularly cut benefits, CRFB created a list, which is below (also see description here). There are clearly fundamental flaws in the Medicaid program that make billions of dollars of waste a prominent feature, not simply a bug. 

If the relatively modest reforms the Republicans are looking to make are unpalatable, the Democrats and Medicaid proponents should wait to see what fiscal chaos waits if the status quo is left to its own devices. It is better that Congress deals with making serious reforms if it wants to avoid even harder choices down the road. However, because politicians tend to operate on myopic thinking motivated by election cycles instead of thinking about long-term sustainability, I suspect that kicking this can down the road is the most likely outcome, one that the American people will pay for dearly.