What's the GOP Medicaid Massacre state of play? The good, the bad & the ugly

There's two new stories out about where things stand with Congressional Republicans obsessive desire to gut Medicaid & kick millions of people off their healthcare coverage in order to give massive tax cuts to billionaires. The first, from Jessie Hellmann, Sandhya Raman and Olivia M. Bridges at Roll Call, has some pretty positive-sounding news:

...Johnson, R-La., said leadership had ruled out two Medicaid policies that could go a long way toward meeting the Energy and Commerce Committee’s $880 billion, 10-year savings target but faced strong pushback from blue-state GOP centrists.

First, Johnson said the emerging package wouldn’t touch the Federal Medical Assistance Percentage, or FMAP, rate — the portion of state Medicaid costs borne by the federal government — for the Medicaid expansion population, which is currently 90 percent.

Johnson also poured cold water over a provision that would implement per capita caps on Medicaid benefits for enrollees in expansion states, though he wasn’t quite as definitive on that front.

...At least one provision remains in the mix: new work requirements for healthy adults in states that expanded Medicaid to receive the 90 percent federal match, a key provision of the 2010 health care law.

“That will be part of the bill, it always has been,” Johnson said on including work requirements.

So it sounds like two of the three ugliest options are out, while one of them is still in.

...“Well — I haven’t ruled it out,” Rep. Chip Roy, R-Texas, posted Tuesday evening on X, formerly Twitter. “It’s necessary to stop robbing from the vulnerable to fund the able-bodied.”

Conservatives have argued that funding for Medicaid expansion means less resources for those in the traditional Medicaid population, mainly children, people with disabilities, some low-income parents and pregnant women.

This is, of course, utter nonsense. The only threat to "resources for those in the traditional Medicaid population" is the GOP's insistence on extending massive tax cuts to millionaires & billionaires.

The other story, by David Dayen of The American Prospect, is where the bad & ugly kicks in. Dayen claims to have seen a recent copy of the "emerging GOP budget," and while it doesn't include either the FMAP or per capita caps as noted in the Roll Call story, it does appear to include not only "Work Requirements" but some additional provisions which are just as nasty:

Medicaid recipients with earnings at or above the federal poverty line would have to pay significant out-of-pocket expenses for their health care coverage, and work requirements would be placed on the program, according to a menu of items in the emerging Republican budget reconciliation proposal seen by the Prospect.

The Medicaid cuts...would also roll back Biden-era rules that improved staffing at nursing homes. And they would alter a number of eligibility and enrollment provisions that would make Medicaid harder to navigate.

...Medicaid recipients making at or above the federal poverty level...would have to pay some money for coverage—either in premiums, co-payments for hospital visits and other treatment, or other fees.

...Making poor people pay more for health care is exactly the kind of effective cut to Medicaid that moderate Republicans have sworn they would not abide...this is a backdoor way of achieving something like that reduction, on the backs of individuals who get Medicaid.

...the item on the list that would create one of the largest cuts to Medicaid is work requirements, which a road map released by the Senate Finance Committee estimated would save $100 billion over ten years.

...61 percent of U.S. adults on Medicaid already work, and a large fraction of those who don’t are either disabled or elderly. The requirement would primarily add red tape to the enrollment system and push people out of Medicaid bureaucratically—as we’ve seen with states like Arkansas that briefly experimented with work requirements during the first Trump administration—while being expensive to implement.

In addition to these, Dayen claims the budget proposal includes:

• Making it harder for Medicaid/Medicare dual-eligibles to enroll & remain covered

• Requiring elderly, disabled & blind enrollees to have their eligibility tested every six months instead of once per year

• Cutting the "retroactive eligibility" time window from 90 days down to 30, which would make it harder for people to obtain nursing home coverage or for those who just got out of a coma to apply for Medicaid

• Reducing nursing home staffing requirements, thus making nursing homes more dangerous

• Forcing the District of Columbia to increase their share of Medicaid expenses from 30% to 50%, costing them $800 million/year (this is the one FMAP drop they're sticking with)

• Cracking down even harder on Medicaid care for immigrants (which is already extremely limited)

• Eliminating the ARPA's flat-out attempt to bribe (there's no better way to put it) non-expansion states to entice them to expand the program

This one isn't really "savings" since the money was already allocated 4 years ago and is mostly just sitting there untouched. Any state which still hasn't expanded Medicaid at this point isn't taking that position out of budget concerns, so it's gonna just sit there unspent for all eternity anyway. Calling it "savings" is like claiming you "saved" money because you found an old $20 bill in your dresser drawer that you forgot was there...but if Republicans want to count it as such, fine, whatever.

• This one is kind of cute, actually: Apparently right now nearly every state, blue or red, uses a trick where they have a tax on their hospitals which is then repaid to them in the form of higher Medicaid reimbursement rates; the reason for this seemingly pointless money shuffle is to push total Medicaid spending up in order to trigger a higher FMAP rate. According to Dayen, putting a cap on this would kick $48 billion of federal spending over to mostly red states.

Dayen says doing all of the above would bring the total up to around $400 billion, less than half the House GOP's target of $880 billion...but it also doesn't include the proposed premiums/co-pays charged to enrollees earning over 100% FPL or other oddball changes.

He also notes that the proposal would hit ACA enrollees as well, via codification of Trump's proposed change to the Premium Adjustment Percentage Index, which I wrote about last month:

CMS proposes to update the methodology for calculating the premium adjustment percentage to establish a premium growth measure that captures premium changes, in both the individual and employer-sponsored insurance (ESI) markets, for the 2026 plan year and beyond. CMS also proposes the plan year 2026 maximum annual limitation on cost sharing, reduced maximum annual limitations on cost sharing, and required contribution percentage using the proposed premium adjustment percentage methodology. This proposed policy would ensure these annual adjustments to ACA parameters align more closely with the changes in premium trends they aim to track.

Maximum out of Pocket (MOOP) is the maximum amount that any ACA plan enrollee has to pay in deductibles, co-pays or coinsurance combined for in-network care over the course of the year.

While the fact sheet doesn't specify the exact amounts involved, according to Norris:

• 2025 Maximum Out of Pocket cap: $9,200 for an individual or $18,400 for the household
• Under current rules: 2026 MOOP would be $10,150 / $20,300 (10.3% higher)
• Proposed rule: 2026 MOOP would be $10,600 / $21,200 (15.2% higher)

Don't get me wrong: The 10.3% MOOP hike for 2026 is bad enough, but jacking it up by 15.2% will be even worse.

As an aside, I should note that codifying the PAPI change is more creative bookkeeping to some extent--that change is gonna be locked in for the next 4 years whether they codify it or not, so at the very least any "savings" for the first 4 years are a phantom. After that it depends on who's President starting in January 2029.

Having said that, remember that this increase in out of pocket costs to the tune of several hundred dollars per year per enrollee would be in addition to the already jaw-dropping spike in net premiums which over 20 million ACA exchange enrollees will be facing if the improved IRA subsidies are allowed to expire at the end of this year, along with the CBO's projected 4.3% premium hike which they expect to kick in as a result of healthy enrollees fleeing the market.