An activist wears a Medicaid shirt as Office of Management and Budget Director Russell Vought testifies before the Senate Appropriations Committee in June 2025.Tom Williams/CQ Roll Call/Zuma
On Tuesday, Senate Republicans passed President Donald Trump’s intensely contested budget bill for the coming fiscal year, returning it to the House in a form that would slash $930 billion from annual federal Medicaid spending across the next decade, require states to implement Medicaid work requirements for adults (with limited exemptions), and strip health insurance from approximately 12 million people.
Trump’s success in attacking Medicaid represents a change from 2017, when disability advocates were able to convince politicians not to repeal the Affordable Care Act, which expanded Medicaid to low-income adults in the 40 states that implemented it. The new bill will undo much of that work in order to fund tax cuts that principally benefit the ultra-rich, with extreme consequences for millions of Americans kicked off insurance rolls.
“This bill is about caviar over kids and hedge funds over health care,” Oregon Sen. Ron Wyden, a Democrat, wrote on social media.
Sharona Hoffman, co-director of Case Western Reserve University’s Law-Medicine Center, believes that Republicans’ new cuts to Medicaid are intended to roll back of Medicaid expansion.
“The goal, I think, is to get states to say, ‘Well, we’re not getting the federal money support, and so we’re going to roll back or undo our expansion of Medicaid,” Hoffman said.
The Affordable Care Act’s Medicaid expansion program led to major increases in low-income adults’ access to health care. A 2022 study published in the Lancet Public Health found, based on CDC data, that Medicaid expansion was linked to a decrease in mortality in the first four years of its implementation.
University of Pennsylvania Carey Law School professor Allison Hoffman, a specialist in medical ethics and health law, expects the bill’s cuts to play out in part through states limiting optional benefits under Medicaid, such as physical therapy, hospice, respiratory care for people on ventilators, and home and community-based services (HCBS)—which, Hoffman says, “help with basic life functioning” for disabled people who qualify. “While they’re optional statutorily under the Medicaid program,” Hoffman continued, “they are anything but optional for people’s livelihoods.”
Those cuts may force disabled people to move into nursing homes, which are also endangered by Medicaid cuts—according to an analysis by Brown University researchers, 579 nursing homes across the US are now at high risk of closure.
Moreover, Allison Hoffman says, “States will be scrambling in the short term in order to be able to even just comply with these new requirements…shifting dollars and shifting people to try to put systems in place for verifying eligibility on a six-month basis, or more frequently as the law requires and allows.”
An October 2021 study published in JAMA Health Forum surveyed primary care physicians in four states that already maintained similar work requirements; the study found that one in five primary care doctors said that they would not fill out a form to exempt their patients with health conditions from work requirements.
Sharona Hoffman, of Case Western, is also concerned that the bill, especially the opaque work requirements, may serve to simply discourage Medicaid enrollment in the first place.
“Part of the problem is it’s a deterrent because people see a work requirement, and they don’t investigate further, and they’ll just not apply for Medicaid, even if they actually could qualify,” she said.
It’s unclear how each state affected by the GOP’s cuts would respond, she continued, but because “most states have balanced budget requirements, they don’t have that much leeway.”
