Republicans are targeting a pillar of Obamacare. Millions of their own voters may pay a price

As the pressure grows on congressional Republicans to identify cuts in Medicaid, they are crashing into a familiar problem: The changes that could save the most money would impose heavy costs on many of their own voters. Several key House Republicans have signaled in recent days that they may try to cut Medicaid spending by rolling back the expansion in eligibility for the working poor included in the Affordable Care Act approved under President Barack Obama. That option may be attractive to Republicans partly because the states that have most aggressively used that authority to expand eligibility mostly lean Democratic. Most House districts where more people than the national average receive health coverage through the Medicaid expansion are also held by Democrats, according to an exclusive new CNN analysis of data from KFF, a non-partisan health care think tank. But GOP constituencies would hardly be immune if Congress rescinds the expansion. Nearly three dozen House Republicans also represent districts where the number of people receiving coverage through that Medicaid expansion exceeds the national district average of about 61,600, the analysis found. And nearly two dozen GOP senators likewise represent states with a substantial population of enrollees covered through the ACA’s Medicaid expansion. “It’s really a similar pattern that we’ve seen with the Affordable Care Act generally – that it’s become so embedded in the health care system and the lives of people across the country that it becomes very hard to take it away,” said Larry Levitt, executive vice president for health policy at KFF. Answers on whether the expansion is too entrenched for congressional Republicans to uproot could begin arriving as soon as May 7, when the House Energy and Commerce Committee, which holds jurisdiction over Medicaid, is expected to start marking up the GOP’s massive budget “reconciliation” plan. Medicaid expansion is a tempting target for GOP budget cuts For all the controversy around both President Donald Trump’s assaults on civil liberties and his tariff moves, it’s likely that the most politically consequential decision congressional Republicans face this year is how to balance spending and tax cuts in the budget package they are formulating. With Trump ruling out cuts in Social Security or Medicare benefits, Medicaid represents by far the largest pot of money available for the reductions that conservative budget hawks are demanding. The House budget resolution has instructed the Energy and Commerce Committee to find $880 billion in savings over the next decade; the Congressional Budget Office recently calculated that even if the committee completely zeroed out the other programs in its purview, it still could not reach that number without cutting Medicaid. Republicans have long viewed Medicaid, which now provides health coverage for about 83 million lower-income Americans, as a more vulnerable target than Medicare, which serves seniors; GOP attempts to cut Medicaid and convert it into a block grant were central to the 1990s budget showdowns between President Bill Clinton and then-House Speaker Newt Gingrich. The bill House Republicans passed in 2017 to repeal the Affordable Care Act included major cutbacks in Medicaid, including a variation on the Gingrich-era block grant proposal. But both the Medicaid population and the GOP electoral coalition have evolved in ways that complicate the party’s choices. The ACA expanded eligibility for Medicaid to far more working poor people. Previously, single childless adults were not eligible for the program at any income level; the ACA allowed states to cover those making up to 138% of the federal poverty level ($15,650 for an individual and about $21,000 for a married couple in 2025). The ACA also allowed states to raise the eligibility level for parents of young children to 138% of the poverty level; many states, particularly in the South, had cut off eligibility for parents at far lower levels before. To encourage states to broaden coverage, the ACA committed Washington to funding 90% of the cost of the expansion population, much more than it pays states for other people covered through Medicaid (generally one-half to three-quarters, depending on the state). All but 10 states have now expanded Medicaid eligibility under the ACA, covering more than 20 million people in all. Even as the ACA expanded Medicaid eligibility up the income ladder to more working poor families, Republicans extended their electoral reach down the income and educational ladder through the political realignment accelerated under Trump. The result, as I wrote recently with CNN senior producer Edward Wu, is that 64 House Republicans now represent districts in which the share of Medicaid recipients exceeds the average for all districts. Far more Republicans than Democrats also represent districts with greater than average prevalence of major health problems including diabetes, obesity and high blood pressure – a reflection of the GOP’s growing consolidation of lower-education, lower-income, often rural House districts. These shifts clearly have made congressional Republicans more uneasy about cutting Medicaid than in the 1990s, or even in 2017. But the Medicaid expansion population has remained a tempting target for them. For one thing, the expansion is tied to the ACA, or Obamacare, which many Republicans, from Trump on down, still disparage. The expansion population, which includes people above the poverty line, is also more susceptible to the traditional argument Republicans have wielded against social welfare programs: that they reward the “undeserving poor” who should be paying their own way. In recent weeks, multiple House Republicans have subtly, but tellingly, distinguished between Medicaid’s traditional enrollees – very low-income parents, people with disabilities, impoverished seniors – and those added under the ACA expansion. House Speaker Mike Johnson has repeatedly called for revoking Medicaid eligibility for “able-bodied workers, for example, young men … who should never be on the program at all.” Even a dozen House Republicans from swing districts who wrote Johnson last week expressing caution about Medicaid reductions made a similar distinction: while they would oppose cuts hurting “vulnerable populations,” they also said they want to “fix flaws in the program that divert resources away from children, seniors, individuals with disabilities, and pregnant women — those who the program was intended to help.” (Emphasis added.) The most specific proposal for reversing the Medicaid expansion has come from Paragon Health Institute, a conservative health care think tank. Paragon has proposed to phase out the enhanced federal assistance for the expansion population over a decade, reducing it to the same reimbursement Washington offers for other recipients. “We’re 15 years post the ACA and I think the question for policy makers is: under what rationale should we paying more for childless adults than kids, pregnant women and people with disabilities on the program?” Brian Blase, the institute’s president and a health policy adviser to Trump during his first term, said in a recent interview. Paragon projects that about 3 million people would lose health care coverage from the shift. That’s largely because it anticipates that most of those removed from Medicaid would qualify for federal subsidies to buy private health insurance through the ACA marketplaces. But the Urban Institute, a center-left think tank, has projected that nearly 11 million people would lose health coverage if Congress revokes the enhanced Medicaid funding for the working poor. If states tried to maintain the current eligibility levels with their own funds, the Urban Institute found, it would require them to increase their Medicaid spending by about 25% annually, a virtual impossibility. Meanwhile, it would become much harder for people kicked off Medicaid to obtain coverage instead through the Obamacare exchanges if Republicans allow the enhanced ACA subsidies approved under President Joe Biden to expire this year, as they have signaled is likely. “If people in the expansion population lose coverage, they may be eligible on paper for the marketplace but many of them would not be able to afford it,” especially if the enhanced subsidies expire, said Allison Orris, director of Medicaid policy at the Center on Budget and Policy Priorities, a liberal group. Medicaid cuts would not spare GOP districts The new analysis of the KFF data by Wu, the senior CNN producer, suggests Republicans are right in their instinct that ending the expansion would rattle more windows in Democratic than GOP-leaning areas. Ninety-eight Democrats represent districts where more people than the average are covered through the expansion, the analysis found. So many congressional Democrats represent big expansion populations , largely because the states that have added the most people through the expansion tend to be places where Democrats are highly competitive, including blue states California, New York, Illinois, Oregon and Virginia, as well as purple battlegrounds like Pennsylvania, Michigan, and Arizona, which are all in the top 10. Democrats, in fact, hold 46 more House seats than Republicans in the states that have expanded Medicaid eligibility, Wu calculated. Conversely, Republicans in Congress are less exposed, largely because the 10 states that have refused to expand Medicaid – headlined by Texas, Florida and Georgia – all lean red, with the exception of Wisconsin (where the GOP-controlled legislature has long blocked expansion). Nearly 40% of House Republicans represent just those 10 states. Even so, the number of House Republicans from expansion states with large numbers of residents – and health care providers – who have come to rely on the new coverage still far exceeds the number of defections that would sink any budget plan. Thirty-two House Republicans also hold seats with an above-average number of expansion beneficiaries; 14 of them represent districts with 80,000 or more Medicaid expansion enrollees. And while the total number of expansion enrollees is greatest in Democratic-held districts (about 12.6 million), the 6.8 million in GOP seats still constitute a very large number of potential voters. Likewise, 22 Republican senators have been elected from the 29 states that have covered at least 100,000 people under the expansion, according to the KFF data. Another factor could make Republicans hesitate about unwinding the expansion: its importance to health care systems in reliably red rural areas. In an interview, North Carolina Medicaid Director Jay Ludlam , for instance, pointed out that rural residents make up twice as big a share of the state’s Medicaid expansion population as they do of the overall population. Experts say that dynamic, which is evident in other states too, is primarily because workers in rural places are less likely to receive health insurance from their employers. Through the expansion, Ludlam said, “We have seen individuals get medicines for heart disease, diabetes, for treatment of seizures – chronic diseases that would go otherwise untreated.” If people lose that coverage, he continued, “initially what you would start to see is an uptick in emergency room visits, which is an incredibly expensive way to provide health care,” with “eventually some of those chronic diseases beginning to have a really adverse impact on the health of many people.” The best example of how all these pressures converge may be Speaker Johnson’s own state of Louisiana. As a lower-income, heavily rural state, Louisiana has been among the greatest beneficiaries of the Medicaid expansion. The state expanded eligibility under Democratic Gov. John Bel Edwards in 2016 and his Republican successor, Gov. Jeff Landry, has not sought to repeal it. According to Kaiser, Louisiana has signed up nearly 800,000 people for the expansion, more than all but four other (and much larger) states. Johnson and fellow Louisiana GOP Reps. Julia Letlow, Clay Higgins and Steve Scalise each have more than 100,000 district residents receiving Medicaid through the expansion, which places all of them among the top eight of all House Republicans. Jan Moller, executive director of Invest in Louisiana, an advocacy group for low-income families, says the Medicaid expansion has also provided a financial lifeline for the state’s health care providers. While rural hospitals are struggling in many states, he notes, none have closed in Louisiana since the expansion. “If you drive around Louisiana,” he added, “you will see a lot of clinics … where they didn’t exist 10 to 15 years ago.” Revoking expansion funding, Moller said, “would be devastating for Louisiana’s budget, and it would seriously threaten health care access for the 1 in 3 Lousianians who depend on Medicaid.” Even people with private insurance or Medicare would be hurt, Moller added, if reduced Medicaid revenue forces hospitals and other providers to close, particularly in rural areas with fewer alternatives. That could be a common problem in many states, Orris said. “Pulling as much money out of the health care system as they are talking about … will hurt everyone in a community,” she said. If congressional Republicans can’t find the votes to directly reverse the expansion, they have signaled they may seek to truncate it by imposing a work requirement on Medicaid recipients. (Missouri GOP Sen. Josh Hawley, for instance, has said he will not support cuts in benefits, but would back a work requirement.) Surveys have found about two-thirds of people on Medicaid already work full- or part-time, and almost all the rest would likely be exempt from any mandate because of factors such as a disability or caring for a family member. But when Arkansas and New Hampshire experimented with work requirements in Trump’s first term, large numbers of people were still thrown off the program for failing to meet the paperwork requirements to document their work. The same could happen with a federal mandate. It would be a bitter irony if a work requirement becomes a vehicle to erase the Medicaid expansion’s historic gains in extending health coverage to the working poor – in red places as well as blue.