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According to the White House, the One Big Beautiful Bill, the president’s signature second-term domestic legislation, does not cut Medicaid. According to any number of budget analysts, including Congress’s own, it guts the health program, bleeding it of $1 trillion in financing and eliminating coverage for 10 million people.
The White House has found a simple way to square this technocratic circle: lie. A trillion dollars in cuts is not a cut; stripping 10 million people of health insurance does not constitute shrinking the program; the president never said “lock her up”; Joe Biden did not win the 2020 election; up is down and down is up.
Other Republicans are adopting a more complicated form of explanatory geometry. The law implements a nationwide work requirement for Medicaid.
Able-bodied adults will have to prove that they are employed, volunteering, or in school in exchange for coverage. “If you are able to work and you refuse to do so, you are defrauding the system,” Speaker Mike Johnson explained on CBS. “You’re cheating the system, and no one in the country believes that that’s right. So there’s a moral component to what we’re doing.” The law does not cut Medicaid, in this telling. It protects the program from abuse.
Johnson’s explanation is no less galling than Donald Trump’s lies. The Medicaid work requirement will not strengthen the program, improve the labor market, or kick lazy cheaters off government benefits. Rather, it will saddle taxpayers with billions of dollars of new costs and low-income Americans with hundreds of millions of hours of busywork. Red tape will cause millions of people to lose health coverage, some of whom will perish because they cannot access care. Republicans are not protecting Medicaid. They are voting to annoy their own constituents to death.
Why does Medicaid need a work requirement in the first place? To prevent the safety net from becoming a hammock, Republicans love to say. But most people on Medicaid are already working if they can work. And Medicaid doesn’t provide its enrollees with cash or a cash-like payment, as the country’s unemployment-insurance, welfare, Social Security, and SNAP programs do. You can’t eat an insurance card. You can’t pay your rent with the guarantee of low co-pays for ambulatory care. Because insurance does not help recipients make ends meet, it does not shrink the labor market, as proved by a randomized controlled trial.
According to the Kaiser Family Foundation, 64 percent of nondisabled adults on Medicaid have a job. Most of the others are not working because they have medical problems or significant caretaking responsibilities, or because they are attending school. Just 8 percent of nondisabled adults seem to be in the category of folks Johnson hopes will be spurred to work by the threat of losing their health coverage. They aren’t 28-year-old guys signing up for public insurance so they can play video games all day. They are retirees and people who can’t find work in their community.
Thus, the work requirement should really be understood as a work-reporting requirement. Starting in 2027, nondisabled adults will have to log in and tell Uncle Sam what they do with their time in order to afford cancer screenings and bloodwork. Each state with an expanded Medicaid program will have to pay a contractor to create, test, and launch a complex intake-and-verification system in 18 months—six, really, because the Department of Health and Human Services is not expected to release detailed rules on the new requirement until midway through next year. In 2019, the Government Accountability Office found that states had spent as much as $463 per beneficiary setting up such systems in the past. Georgia, the only state that currently has a Medicaid work requirement, spends $9 on overhead for every $1 it spends on medical care through the initiative.
More than 20 million Americans will have to set up accounts to let the state know that they are in compliance with the work requirement, out of compliance, or not subject to it. This likely means collecting documents, uploading them, waiting for verifications, submitting sensitive personal data, and appealing incorrect determinations, all on what, history shows, will surely be a clunky, faulty system backed by a too-small cadre of overworked and underpaid civil servants. A broken laptop or a faulty internet connection might cause an individual to get rejected; a missed phone call from a caseworker might lead to a person missing out on care. Washington is shifting the burden of public administration onto individuals, and counting on people to fail.
In general, work requirements are far better at weeding out worthy participants than they are at motivating noncompliant ones. Roughly 240,000 Georgians are eligible for the state’s work-for-Medicaid initiative, which covers very poor nondisabled adults. Only 5,500 are actually enrolled, thanks to the complexity of the program’s rules and the impossibility of its portal. Arkansas kicked nearly 20,000 people off Medicaid when it required applicants to prove that they were working in 2018 and 2019; the change had no effect on employment. One analysis of the One Big Beautiful Bill suggests that each “appropriate” disenrollment from Medicaid will cost taxpayers $5,000 in bureaucratic overhead—not far off from how much Medicaid spends per person to begin with.
Trump’s law doesn’t protect Medicaid. It requires Americans to spend hundreds of millions of hours a year filling out tedious, unnecessary paperwork. It will cause millions of Americans to lose their health coverage, limiting their access to care and forcing them into debt. An estimated 50,000 people will die each year—many thanks to red tape.
According to the White House, the One Big Beautiful Bill, the president’s signature second-term domestic legislation, does not cut Medicaid. According to any number of budget analysts, including Congress’s own, it guts the health program, bleeding it of $1 trillion in financing and eliminating coverage for 10 million people.
The White House has found a simple way to square this technocratic circle: lie. A trillion dollars in cuts is not a cut; stripping 10 million people of health insurance does not constitute shrinking the program; the president never said “lock her up”; Joe Biden did not win the 2020 election; up is down and down is up.
Other Republicans are adopting a more complicated form of explanatory geometry. The law implements a nationwide work requirement for Medicaid.
Able-bodied adults will have to prove that they are employed, volunteering, or in school in exchange for coverage. “If you are able to work and you refuse to do so, you are defrauding the system,” Speaker Mike Johnson explained on CBS. “You’re cheating the system, and no one in the country believes that that’s right. So there’s a moral component to what we’re doing.” The law does not cut Medicaid, in this telling. It protects the program from abuse.
Johnson’s explanation is no less galling than Donald Trump’s lies. The Medicaid work requirement will not strengthen the program, improve the labor market, or kick lazy cheaters off government benefits. Rather, it will saddle taxpayers with billions of dollars of new costs and low-income Americans with hundreds of millions of hours of busywork. Red tape will cause millions of people to lose health coverage, some of whom will perish because they cannot access care. Republicans are not protecting Medicaid. They are voting to annoy their own constituents to death.
Why does Medicaid need a work requirement in the first place? To prevent the safety net from becoming a hammock, Republicans love to say. But most people on Medicaid are already working if they can work. And Medicaid doesn’t provide its enrollees with cash or a cash-like payment, as the country’s unemployment-insurance, welfare, Social Security, and SNAP programs do. You can’t eat an insurance card. You can’t pay your rent with the guarantee of low co-pays for ambulatory care. Because insurance does not help recipients make ends meet, it does not shrink the labor market, as proved by a randomized controlled trial.
According to the Kaiser Family Foundation, 64 percent of nondisabled adults on Medicaid have a job. Most of the others are not working because they have medical problems or significant caretaking responsibilities, or because they are attending school. Just 8 percent of nondisabled adults seem to be in the category of folks Johnson hopes will be spurred to work by the threat of losing their health coverage. They aren’t 28-year-old guys signing up for public insurance so they can play video games all day. They are retirees and people who can’t find work in their community.
Thus, the work requirement should really be understood as a work-reporting requirement. Starting in 2027, nondisabled adults will have to log in and tell Uncle Sam what they do with their time in order to afford cancer screenings and bloodwork. Each state with an expanded Medicaid program will have to pay a contractor to create, test, and launch a complex intake-and-verification system in 18 months—six, really, because the Department of Health and Human Services is not expected to release detailed rules on the new requirement until midway through next year. In 2019, the Government Accountability Office found that states had spent as much as $463 per beneficiary setting up such systems in the past. Georgia, the only state that currently has a Medicaid work requirement, spends $9 on overhead for every $1 it spends on medical care through the initiative.
More than 20 million Americans will have to set up accounts to let the state know that they are in compliance with the work requirement, out of compliance, or not subject to it. This likely means collecting documents, uploading them, waiting for verifications, submitting sensitive personal data, and appealing incorrect determinations, all on what, history shows, will surely be a clunky, faulty system backed by a too-small cadre of overworked and underpaid civil servants. A broken laptop or a faulty internet connection might cause an individual to get rejected; a missed phone call from a caseworker might lead to a person missing out on care. Washington is shifting the burden of public administration onto individuals, and counting on people to fail.
In general, work requirements are far better at weeding out worthy participants than they are at motivating noncompliant ones. Roughly 240,000 Georgians are eligible for the state’s work-for-Medicaid initiative, which covers very poor nondisabled adults. Only 5,500 are actually enrolled, thanks to the complexity of the program’s rules and the impossibility of its portal. Arkansas kicked nearly 20,000 people off Medicaid when it required applicants to prove that they were working in 2018 and 2019; the change had no effect on employment. One analysis of the One Big Beautiful Bill suggests that each “appropriate” disenrollment from Medicaid will cost taxpayers $5,000 in bureaucratic overhead—not far off from how much Medicaid spends per person to begin with.
Trump’s law doesn’t protect Medicaid. It requires Americans to spend hundreds of millions of hours a year filling out tedious, unnecessary paperwork. It will cause millions of Americans to lose their health coverage, limiting their access to care and forcing them into debt. An estimated 50,000 people will die each year—many thanks to red tape.
