Only in America could arguments for cutting healthcare access be so artful

The phrase “only in America” usually refers to the upside of national exceptionalism, but in the context of healthcare, the meaning is often negative. That’s the case with current efforts to cut Medicaid — now the nation’s largest healthcare program in terms of enrollment — to pay for large tax cuts that will primarily benefit the highest-income Americans.^a

The likelihood that Medicaid cuts would also cause millions of people to lose health insurance is an only-in-America phenomenon in multiple respects. Among rich nations, only in America is a lack of universal health coverage so completely the norm that many politicians see little harm in cutting back coverage if the nation’s wealthiest will benefit. And only in America could they be so brazen as to justify retrenchment for utterly specious reasons.

The false premise about Medicaid’s intended purpose

Perhaps the most egregious falsehood now being invoked in defense of cuts is that Medicaid has strayed from its fixed programmatic characteristics. In this imagined state, Medicaid is for “children, mothers, people with disabilities and the elderly — for whom the program was designed,” wrote Rep. Brett Guthrie (R-Ky.), who chairs the congressional panel that crafted proposed Medicaid cuts.^b The further implication is that Medicaid shouldn’t cover the so-called “able-bodied” — fathers and non- elderly, non-disabled men and women without dependent children — to preserve coverage for these “vulnerable populations.”

The reality is that Medicaid’s contours have been evolving since its enactment in 1965 as the successor to a system of federal medical payments supporting people on welfare. In crafting a complex new federal-state partnership “to provide States the opportunity to receive Federal funding for services provided to many groups of categorically eligible needy people,” Medicaid’s authors explicitly “left it to future partisans to resolve different agendas for the appropriate role of the program.”^c

As a result, Medicaid has been in nearly constant flux for decades as benefits, eligibility and state funding mechanisms have changed. The 1996 federal welfare reform law cut the last direct links that made welfare recipients automatically eligible for Medicaid and cre ated separate enrollment requirements for both programs.^d Subsequent changes such as the Affordable Care Act’s Medicaid expansion provisions have swelled the program’s ranks to include millions of “able-bodied” individuals earning up to 1.38 times the federal poverty level.

Medicaid’s current status

With total Medicaid enrollment now projected at 79.4 million in 2025, or about 21% of the U.S. population — already down from 2023 due to the “unwinding” of pandemic-era coverage provisions — Medicaid is now an integral part of U.S. healthcare coverage and financing. In fiscal 2024, the program constituted about 18% of national health expenditures, with spending for Medicaid and the Children’s Health insurance program at $914 billion (64% federal and 36% from state and local funding and provider taxes).^e

Given current systemic stresses, including inflation and rising demand for healthcare services among all populations, it isn’t just safety-net or rural providers that are threatened by Medicaid cuts. The broader economic consequences would also be harmful, as analyses show large job losses and lower state tax revenues from the combined cuts now proposed for both Medicaid and the Supplemental Nutrition Assistance Program (SNAP).^f

The view that proposed cuts may also be “morally wrong and politically suicidal,” as Missouri Republican Sen. Josh Hawley has said, is reinforced by the specious arguments of others defending cuts:^g Among them:

• That the cuts are aimed at eliminating waste, fraud and abuse in the program^h
• That drawing down federal matching funds partly through provider taxes constitutes “money laundering”ⁱ
• That covering the “able-bodied” through the Medicaid expansion has resulted in less healthcare access for “vulnerable populations” and hasn’t improved health (These assertions are refuted by other evidence.)^j

Even supposed approaches for curtailing Medicaid enrollment by the allegedly slothful, such as mandatory work requirements, are undercut by the evidence that the vast majority of enrollees are already working.^k

A lamentable mindset

There are many worthy debates to be had about the level of U.S. healthcare spending, affordability, the role of prices and how best to finance access to care. But only in America has toying with allocating health coverage using arguments that amount to chicanery and nonsense become a cruel national sport. 

Footnotes

a. See, for example, “Distributional effects of House budget reconciliation as of Thursday, May 15,” budget model, Penn Wharton University of Pennsylvania, May 16, 2025.
b. Guthrie, B., “A common sense budget reconciliation bill,” WSJ, May 11, 2025.
c. Moore, J.D., Smith, D.G., “Legislating Medicaid: considering Medicaid and its origins,” Health Care Financing Review, winter 2005.
d. Moore, J.D., “Welfare reform and its impact on Medicaid: An update,” National Health Policy Forum, Feb. 26, 1999.
e. Peter G. Peterson Foundation, “How do states pay for Medicaid?” April 16, 2025.
f. Ku, L., et al., “How potential federal cuts to Medicaid and SNAP could trigger the loss of a million-plus jobs, reduced economic activity, and less state revenue,” The Commonwealth Fund, issue brief, March 25, 2025.
g. Morning Joe, “‘Morally wrong, politically suicidal’: Republican senator says no Medicaid cuts,” MSNBC, May 15, 2025.
h. Mondeaux, C., “Sen. Lee: More should be done to cut waste, fraud and abuse from Medicaid,” Deseret News, May 12, 2025.
i. Blase, B., “New report: Addressing Medicaid money laundering,” Paragon Health Institute, March 26, 2025.
j. See for example, Graves, J.A., et al., “Medicaid expansion slowed rates of health decline for low-income adults in Southern states,” Health Affairs, January 2020.
k. Tolbert, J., et al., “Understanding the intersection of Medicaid and work: An update,” KFF, Feb. 4, 2025.