After the passage of President Trump’s “One, Big Beautiful Bill” (its literal title, hereafter OBBB), you no doubt have seen some fairly apocalyptic predictions about Medicaid. Keep in mind that these are all predictions. What can we say factually about the program and what the OBBB says about it?
What is Medicaid? Formally Title XIX of the Social Security Act of 1965, Medicaid is a federal-state partnership that provides medical assistance to low-income individuals and families who cannot afford private health insurance. I bolded the key terms. The federal government provides most of the funds (two-thirds) and dictates who always qualifies and what care must be covered. The states provide the rest of the funding and administer the program (with significant variance between the states). It was designed to provide health care to the poorest and neediest: a truly charitable endeavor. In 1965, about 2% of Americans were covered by Medicaid; today it is around 20%. Are there ten times more poor and needy today? Of course not. The change in enrollment is driven by increasing eligibility over time. This chart details some of the changes:

Form the 1970s through 2008, the number of Americans enrolled in Medicaid was driven by population increases (200 million to 300 million approximately) and by more inclusive rules (for example, greater eligibility for women, children, and people with disabilities). The biggest change begins in 2010, when President Obama signed into the law the Affordable Care Act (ACA in the chart, hereafter “Obamacare”).
This law greatly decreased the number of those uninsured by making health insurance mandatory (the personal insurance mandate, backed by a tax penalty), by offering Obamacare marketplaces where insurance could be purchased with a means-tested federal government subsidy, and by increasing eligibility for Medicaid. Most people don’t realize that in the great debate over Obamacare (for example, the personal mandate was ruled constitutional by the US Supreme Court, but effectively rescinded by the Trump administration in 2017 when the tax penalty was set to zero), most of the gains in insurance coverage were due to the simple increase in eligibility in Medicaid (which didn’t require any grand new law).
In the chart, Medicaid enrollment sharply increases after 2008, going from about 40 million to over 90 million at peak. This was also accelerated by a pandemic-era (2020) legal change, called continuous enrollment, which required states to leave persons receiving Medicaid on the rolls whether they still qualified or not. The point here was to avoid cutting people off from their only health insurance during a pandemic. Medicaid enrollment currently stands at around 80 million, after continuous enrollment was cancelled in 2023. The point here is that 15 million people were removed from Medicaid under the Biden administration, not because the government is cruel, but because they were not eligible, under the law.
While most of Medicaid funding goes for poor people over 65 years old and those disabled, the fastest growing segment of Medicaid enrollees is (non-disabled) adult men, age 18-40 who are eligible under the relaxed Obamacare income rules rules. The second fastest-growing group is children, oftentimes children of adults eligible for Medicaid. The federal cost of Medicaid has skyrocketed: from US$333B before Obamacare to US$860B in 2023.

Now to the OBBB. It:
- Requires able-bodied adults aged 19-64, who are enrolled in Medicaid through the Affordable Care Act’s expansion, to work/volunteer/participate in other approved activities for at least 80 hours per month to maintain their coverage.
- Restricts state provider-tax arrangements. This sounds obscure, and it is, but some states taxed medical providers, then charged the federal government too, in effect “laundering” federal resources for state priorities that otherwise would be prohibited. California, for example, used the money to provide health insurance for illegal aliens/undocumented persons. It wasn’t technically illegal, but it most specifically is, now.
- Eliminates certain recent increases in federal funding to states to encourage them to increase Medicaid eligibility, and increases eligibility checks from once every year to once every six months.
- Denies eligibility to non-citizens, some lawful permanent residents, and refugees.
- That’s it. Notice there is no change to eligibility for pregnant women, poor single parents, the disabled, or any other groups.
There are endless estimates about how much money will be “cut/saved,” how many people will be dis-enrolled, how many people will die. It is important to note that all of these estimates are, in fact, just estimates. Estimates of how people will respond to Medicaid and other changes in law have been poor, at best. When the Trump administration eliminated the personal mandate, the Congressional Budget Office (CBO) estimated 15 million people (healthy young folks who didn’t care to have any insurance anyway) would quit; they didn’t quit, at all. Now CBO estimates between 10 and 15 million will lose coverage. Are they right this time? No one knows.
Look at the facts of Medicaid coverage above, and the OBBB provisions. Ask yourself these questions:
- Should Medicaid be a program for the poorest and neediest, or a mini-form of universal medical coverage?
- Should working-age men with no disabilities be required to work/volunteer 20 hours a week in order to have government-provided health coverage?
- Should non-citizens have the same healthcare coverage as poor/needy Americans?
- Should states be permitted to use federal resources for programs not authorized by federal rules?
- If the estimated 15 million loss in enrollees under the Trump administration bothers you, how do you feel about the 15 million actually dis-enrolled under the Biden administration?
- How much of the increase in Medicaid enrollment and spending is consistent with the program’s intent? and finally,
- How much are you willing to pay for all of this? Before you toss out “what about ________?” naming another budget item you would rather cut, look at this chart of current federal appropriations. If you can’t cut Social Security, Medicare, or Interest on the debt, the remaining options are limited!

Don’t engage with the headlines designed to enrage you; think! I am not saying cuts to Medicaid are a great idea, but neither are they catastrophic. If you want to join in and debate the topic, first learn something about it. Or at least something more than “people will die” or “what about the children?”






