Republicans are facing a nationwide backlash over the fate of Medicaid — but the potential program cuts are most threatening in seven conservative-leaning states where voters have cast ballots to expand the entitlement in recent years.
It’s a growing problem as Republicans hunt for enough savings to pay for the White House’s proposed tax cuts.
Republican Sen. Mike Rounds of South Dakota, which has enrolled more than 24,000 people in Medicaid since voters expanded the insurance program for low-income people in 2022, told POLITICO he’s been arguing against some of his own party’s proposals. One would reduce significantly how much funding for the program comes from the federal government.
“That’s not a cost cutting measure — that’s a cost transfer,” he said. “And when you’ve got partnerships with the states, you shouldn’t be doing that without having them involved in the discussion.”
Republicans face similar skepticism across red and purple swaths of the country where voters have used ballot initiatives to expand Medicaid since Congress last targeted the safety net health insurance program in 2017 – not only in South Dakota, but also in Idaho, Nebraska, Maine, Oklahoma, Missouri and Utah. President Donald Trump won all of those states except Maine. And even there, he won an electoral vote by defeating Kamala Harris in the state’s 2nd Congressional District, where nearly a third of people are enrolled in Medicaid.
The president’s conflicting guidance to Congress about whether and how much to cut from the program suggests he is aware of the political peril.
Additional states could expand Medicaid in the coming years, making future rollbacks even more challenging. There’s currently a campaign underway in Florida to put expansion on the ballot in 2026, underscoring the popularity of Medicaid even in the most MAGA-friendly states.
“Cutting Medicaid seems to be popular with some Republican elites and some right wing think tanks that are getting funded by some right wing billionaires, but they’re unquestionably not popular with the Republican voters,” Joan Alker, the executive director of the Center for Children and Families at Georgetown University’s McCourt School of Public Policy, told reporters at a briefing on Medicaid this week. “We’ve seen many polls recently asking voters to rank what they wanted … and cutting Medicaid was literally the last on the list for voters of all stripes.”
Coalitions on the ground in the seven states that passed Medicaid expansion initiatives — made up of powerful hospital associations, grassroots advocacy groups and other strange bedfellows — are now re-mobilizing to defend them. They’re sending people to town halls. They’re publishing op-eds in local newspapers. They’re flooding the phone lines of their members of Congress. And they’re mulling a revival of some of the more aggressive tactics activists used to protest attempts to repeal the Affordable Care Act in 2017.
“We’re going back to the old playbook,” said Matt Slonaker, the executive director of the Utah Health Policy Project who spearheaded the state’s ballot initiative campaign in 2018. “It’s always hard to get folks to act, but they seem to be really, really ready to do this right now.”
With pressure mounting to find hundreds of billions in savings, lawmakers who are usually on board with slashing government spending remain on high alert about the blowback they could face in their states over Medicaid. And as they struggle to keep their members united behind Trump’s budget plan, GOP leadership is taking notice.
House Speaker Mike Johnson on Wednesday night backed away from some of the most sweeping changes the GOP had been debating, including capping the funds states get for each Medicaid enrollee and rolling back federal support for expansion states, even as he dismissed outrage his members have recently faced over threatened cuts at fiery town halls across the country as the work of “paid protesters.”
“All this attention is being paid to Medicaid because that’s the Democrats’ talking point,” Johnson said. “We’re talking about finding efficiencies in every program, but not cutting benefits for people who rightly deserve them.”
Pro-expansion health care groups in these seven red and purple states mounted expensive and time-consuming ballot initiative campaigns to circumvent conservative state legislatures and governors who refused to expand Medicaid, and some of those same state officials are currently working to roll back the expanded coverage their constituents enacted.
That’s left Republicans on Capitol Hill from Medicaid-expansion states as the loudest — and in some cases the only — effective voices of opposition to the proposed cuts now that Democrats are locked out of power. And while some House Republicans who represent red districts are feeling the heat, senators will have to answer to their entire state.
“I don’t quite think Republicans know the backlash they’re in for,” said Brad Woodhouse, a former Democratic National Committee official who now runs the progressive health care advocacy group Protect Our Care. “And it’s going to be a particularly bitter pill in these states that have used ballot initiatives because in those cases, the voters have really spoken about their preference.”
Republican Sens. Josh Hawley of Missouri and Susan Collins of Maine — both of whom hail from states that expanded Medicaid by ballot measure — crossed the aisle earlier this week to support a Democratic amendment to the Senate budget resolution that would have blocked tax cuts for the wealthy if any Medicaid funding is cut.
Hawley, who represents about 326,000 people who became eligible for Medicaid under the state’s 2021 expansion, has said he wouldn’t support “severe” cuts to Medicaid — specifically cuts that would lead to reduced benefits — calling it a “red line” for securing his vote.
The politics are especially tricky for representatives of more rural states where Medicaid has been a lifeline for hospitals struggling to keep the lights on — hospitals that in some instances are among the state’s biggest employers.
In Idaho, for example, voters approved expanding Medicaid in 2018 with 61 percent support, extending coverage to about 90,000 more residents. But if federal funding for Medicaid decreases as a result of the current negotiations in Washington, the state legislature has the power to intervene and potentially repeal the expansion. Idaho House Minority Leader Ilana Rubel, a Democrat, is among those warning that such an outcome would threaten the state’s remaining rural hospitals.
“That’s a disaster, not only for the people on Medicaid, but for the people on private insurance,” Rubel said. “Because when you live in these rural areas, you know you can have the best insurance in the world, but if the hospital in your area has gone out of business and you fall off a ladder or have a heart attack, there will be nobody to help you.”
Yet not every Republican from an expansion state is worried about the sweeping reforms hardliners in their caucus are pushing for.
Sen. James Lankford of Oklahoma, where more than 245,000 people became eligible for coverage after the state voted to expand Medicaid in 2020, echoed Speaker Johnson’s argument that the final budget would not impact individuals’ health care benefits and said he hadn’t heard from concerned citizens about it.
“I have not heard anyone talking about cutting off Medicaid to people,” he said. “It has been dealing with formulas. It’s been dealing with fraud.”
Utah Sen. John Curtis told POLITICO this week that after discussing the matter with Republican Gov. Spencer Cox, he’s not sweating the political implications.
He said he’s “not near as concerned” about cuts to the safety net program as he is “about the fiscal irresponsibility that we’re facing,” adding that he’s “in total harmony with our state leaders on this.”
Medicaid enrollment in Utah grew nearly 60 percent after a ballot measure expanding the program passed in 2018. But Utah is among the nine states that has a “trigger” law in place to automatically end Medicaid expansion or require major changes to the program if federal funds decline, threatening coverage for millions of people.
For Curtis, that’s a feature rather than a bug.
“Our state is one of more fiscally responsible states, in my opinion, and they saw this coming,” he said.
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