What we wrote in the New York Times about Medicaid cuts

Republicans want to make it impossible for eligible clients to access the safety net

A few days ago, four Trump Cabinet members, wrote an opinion piece in the New York Times trumpeting the addition of work requirements to Medicaid and other safety net programs. This included RFK Jr. and Dr. Oz, two officials who are charged with protecting the health of the public. They declared that “The good news is that history shows us that work requirements work.”

History shows no such thing. Indeed, the evidence is closer to the opposite—with perhaps the greatest irony that most people still will be eligible, but will get kicked off because they can’t manage the paperwork. And as we argue today in the New York Times, work requirements are just one piece in a package of proposed cuts to Medicaid, and more broadly in the Republican agenda, to drown people in administrative burden. It’s politically expedient, concealing cuts in confusing bureaucratic changes, but ultimately devastating for the people who are eligible for—and desperately need— social safety net benefits.

As we have written about before, safety net work requirements do not work. Or, they work only if your goal is to reduce access to services, while largely failing to increase labor market participation. See our prior post here, and a longer paper in the Journal of Economic Perspectives where we used work requirements as an example of an administrative burden where the evidence is clear that they will do great damage while providing little benefit. Work requirements require paperwork, not work, and lots of us struggle with paperwork. Worryingly, work requirements appear to be especially damaging to vulnerable populations, such those who are already in poor health.

To it’s credit, the Times also published Matt Bruenig’s excellent article explaining how work requirements are cruel and pointless, which emphasized that most people who can work are working.

States that have embraced work requirements serve as canaries in the coal mine. When Georgia and Arkansas implemented Medicaid work requirements nearly all of the people that lost coverage did actually meet the requirements – it was just too hard to demonstrate they did. In Georgia, just 12,000 of 250,000 eligible citizens were able to access the benefit, and spending on administrative costs exceeds spending on actual health care. Jen Pahlka described work requirements as "welfare for Deloitte”, the consulting firm that administers the program. In Arkansas, half of those who lost coverage reported serious problems paying off medical debt 56 percent delayed care and 64 percent delayed medication due to cost.

You can read our contribution to the debate here: the key takeaway is that it is not just work requirements. Republicans are building a regime of burdens that will drown people on Medicaid in red tape. And it’s not just Medicaid. They are going to embed more administrative burdens in other policies. See Greg Leiserson’s explanation of the plan to make the Earned Income Tax Credit more difficult to access. They are doing this quickly, running debates and holding votes in the middle of the night before people can fully digest what is in the bill. They are doing this because they know that their policies do not hold up to scrutiny.

Partly this is a matter of political philosophy. Conservatives are more tolerant of administrative burdens generally, and especially in safety net programs like Medicaid, even as the public broadly supports making such programs more accessible. But those discussions should be informed by evidence around the pros and cons of administrative burdens. Even as Republicans are uncritically applauding DOGE’s gutting of government capacity in the name of reducing bureaucracy, they are enthusiastically raising the time tax in popular programs that affect most Americans.

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Republicans Will Use Paperwork to Kick Americans Off Health Care

Appearing on Fox News, the Republican chair of the House Ways and Means Committee, Jason Smith, noted the need for Medicaid “cuts,” but then quickly corrected himself: “Medicaid reforms, I should say.” The Freudian slip highlighted the impossible political situation he and his fellow Republicans are in. It’s hard to imagine a path to extend President Trump’s tax breaks for the wealthy without slashing Medicaid — but most Americans, including the Republicans’ own voters, are opposed to restricting benefits.

To control the political damage, Republicans are pursuing a strategy to reduce benefits, while pretending otherwise. They’ve mostly abandoned transparent cuts, such as eligibility changes or spending reductions to states, because it’s easy for voters to understand that damage. Instead, Republicans are opting for opaque cuts, which will shed millions of eligible beneficiaries by overwhelming them with pointless paperwork and other needlessly complicated administrative requirements.

The proposed House bill reverses what has been a quiet revolution in Medicaid — making it easier for people who are eligible to obtain benefits. Over the past 15 years, reforms have included simplifying applications, eliminating confusing paperwork and automating processes, especially when it comes to renewing benefits. Surveys show that the public supports such service improvements.

In short, America has not only expanded who is eligible for Medicaid, but also made it easier for eligible people to get benefits. The eligibility expansions, which led to large increases in enrollment and spending, were so effective because they were paired with burden reductions. For example, allowing children to stay continuously on Medicaid for 12 months, rather than six months, may have halved the number of eligible children who erroneously lose coverage. During the Trump administration, some states added new barriers, which caused a nearly 6 percent loss in coverage among children within six months.

Democrats learned that addressing these easily overlooked administrative burdens was essential to ensure that more Americans have health insurance. Republicans learned a different lesson. Precisely because they’re overlooked, administrative burdens are an excellent political tool to accomplish unpopular policy goals. Consequently, Republicans are proposing to increase burdens to ensure large coverage loss among the eligible.

Work requirements have received the most attention, with much of the criticism focused on the ethics of cutting costs by making health care access contingent on employment. But those debates are a distraction from Republicans’ actual goal: pushing eligible people off the program. If you account for Medicaid beneficiaries who are already working — and those excluded from work requirements because of disability or caregiving responsibilities — almost no one should lose coverage. But when Arkansas adopted work requirements in 2018, nearly all of the people who lost coverage had met the requirements. They simply couldn’t manage the paperwork to prove it.

Digging deeper into the bill, the pattern of using burdens to quietly kick off eligible beneficiaries becomes undeniable. The bill would pause a series of comprehensive new rules, issued by the Biden administration, to make it easier for people to navigate Medicaid’s eligibility and renewal processes. The mixture of reforms would have ensured that millions of people who were eligible for benefits, including disabled people, actually received them.

The Republicans’ bill would also require more beneficiaries to renew their coverage twice a year. Since the passage of Obamacare, most people have had to repeat this process only annually. Not only would the twice-a-year requirement cost people a lot of additional time and effort, many eligible people would lose coverage during this process. By some estimates, one-third of people who lose Medicaid quickly regain it, signaling they lost it because of procedural mistakes rather than becoming ineligible. That is why recent reforms have lengthened periods between renewals.

Another new burden would require beneficiaries to pay when they go to the doctor. Co-pays reduce health care use, but do not produce cost savings. One study found that even a $12.50 co-pay discouraged women from getting a mammogram. Moreover, there’s evidence that some of the people needing health care the most are among the most likely not to get it.

Finally, congressional Republicans want to create incentives for states to add even more administrative burdens. They’re planning to increase penalties for states that make enrollment errors, which would encourage them to add excessive documentation requirements. Given that the vast majority of fraud and wasteful spending is perpetrated by private health insurers that contract with Medicaid or health care providers, the effect would be to push eligible people off the program more than it reduces any erroneous payments.

Republicans claim that such burdens serve virtuous policy goals, like reducing fraud and welfare dependency. But if millions of people are going to lose access to health insurance, let’s at least be honest about how this is likely to play out and why Republicans are pushing this agenda. The push to make public health insurance less accessible is driven not by concerns about what best serves the public. Instead, the most vulnerable will be made worse off, all to fund a tax cut that most benefits the rich.