The GOP is on the cusp of major changes to Medicaid. Ready your coverage now.

As congressional Republicans continue debating proposed cuts to Medicaid funding, they’re running up against a key fact: Any reductions could have major impacts on the 71 million people who rely on the public health insurance program. 

It’s up to journalists to translate those potential impacts into stories. Focusing on strong data and personal narratives can lead to powerful reporting as communities nationwide grapple with the potential shortfalls, said Alice Miranda Ollstein, a senior health care reporter for Politico. 

“Doing the work of finding that information and those people who are living through this is really the way to go,” she said in a recent Center for Health Journalism webinar. 

The details of any federal cuts to Medicaid, the federal-state health insurance for low-income children and adults, are still unclear. Members of the House Energy and Commerce committee are slated to begin marking up key parts of the GOP bill on Tuesday.

Congress’ budget resolution, which seeks to extend Trump’s 2017 tax cuts, tasks the house committee that oversees Medicaid to cut the federal deficit by $880 billion over 10 years. If Medicare cuts are off the table, as Trump has insisted they are, meeting those budget goals would require major cuts to Medicaid, explains a KFF report.

In 2023, the federal government paid 69% of the $890 billion in Medicaid program costs while states paid 31%, according to the Commonwealth Fund. While there are many ideas circulating on how Republicans might cut costs, a key theme is shifting some of those federal costs to the states, said Edwin Park, a research professor at the Georgetown University McCourt School of Public Policy in the recent webinar. 

Park drilled down on several key possibilities, including: 

• Creating work requirements:  This would require individuals who receive Medicaid benefits to document that they’re working a certain number of hours a month — generally 80 — or be disenrolled. There would be exemptions for some plan participants such as children and people with disabilities. Democrats counter that most recipients are already working and that such requirements lead to eligible people losing coverage due to onerous paperwork requirements and eligibility checks.
• Cutting state tax loophole: Congressional Republicans are considering removing a tax maneuver that allows states to tax health care providers. These taxes inflate the state’s Medicaid spending, which allows them to collect more matching federal funds, explains a recent New York Times article. The state can return these extra funds to the providers as higher payments for Medicaid care.
• Imposing per capita caps: Instead of providing a share of total program costs, this move would limit the federal contribution for Medicaid beneficiaries. As part of the Affordable Care Act’s Medicaid expansion, the federal government pays 90% of the cost for these Medicaid expansion enrollees, compared to a much lower percentage (it varies by state) for other plan participants. Limiting federal dollars would force states to kick in more money to keep people insured — or end their Medicaid expansion programs.  

Recent news reports suggest that some of those more dire cuts are off the table, with House members coalescing around more moderate reforms. “The committee is eyeing a number of changes to Medicaid, including work requirements and more frequent eligibility checks as well as a crackdown on noncitizen enrollment,” Politico reported last week.

States will face tough decisions ahead 

Since states have to balance their budgets, federal cuts would require tough choices ahead, Park added. In order to keep people covered by Medicaid, they could respond in a variety of ways, such as tax increases, cuts in other areas such as education, or reductions in provider reimbursements. They could also reduce the number of people covered by Medicaid. The populations most at risk for losing their health care would depend on the individual state’s decision.

“Each state will have to figure out how they’re going to balance the budget in response, so the cuts will look different in every state,” Park said. But federal cuts would mean that “states would not be able to sustain their current Medicaid programs as is over the long run.”

As part of the Affordable Care Act’s expansion, 40 states have extended Medicaid benefits to more adults — people who made too much money previously to qualify for the program, but struggled to pay for private insurance. Nine states have trigger laws that would end their ACA expansion programs if they were to lose federal funding decreases, according to a KFF analysis. 

California’s big challenges 

California’s experience offers a window into the challenges states could face. There, after numerous Medicaid expansions — including to undocumented adults — about one in three state residents are now enrolled in Medi-Cal, California’s version of Medicaid. If California lost federal funding support, there’s no way the state, which is already facing budget challenges, could backfill that gap, said Mari Cantwell, the former state Medicaid director who now serves as a managing director at Sellers Dorsey, a health care consulting firm. 

The most likely cuts would probably first hit those populations that most recently received benefits, such as undocumented adults, she said in a March presentation to the Center for Health Journalism’s California Health Equity Fellows. Other potential cuts include benefits such as dental, vision or costly prescription drug benefits.

Provider reimbursement rates could also be lowered, which would have ripple effects if health care organizations decide to forego taking Medicaid patients. Reimbursement cuts could also impact already struggling hospitals that may decide to shutter birthing or trauma centers, which are costly to maintain. Eliminating programs such as California Advancing and Innovating Medi-Cal (CalAIM), which uses Medicaid dollars in nontraditional ways such as housing support, will likely be in jeopardy, too.

“I think we will see people be sicker, we’ll see people back being homeless, we’ll see people struggling to navigate our system, and maybe going back to using ER as their primary source of care,” Cantwell said.  

Reports should explore unexpected impacts

Amid all these policy possibilities, reporters can illuminate what’s at stake by telling compelling stories of Medicaid’s role in the health of their communities, said Ana B. Ibarra, who covers health care for CalMatters. At the Center’s California fellowship last month, Ibarra advised fellow journalists to think about who relies on Medicaid.

For example, while many think older adults would not be impacted because they primarily depend on Medicare, some seniors also rely on Medicaid for services such as long-term care, which Medicare doesn’t cover. School-based health centers are another area to explore — and school administrators might be eager to talk since these services, such as mental health services and counseling, are helping students in their schools, she added. 

Celia Valdez, who has been working in health outreach for over 28 years as the health outreach and navigation director with Maternal and Child Health Access, a Los Angeles-based nonprofit, urged reporters to tell the stories of Medicaid’s real-world impacts. For example, she shared the story of a client named Amber, who has a 72-year-old diabetic husband who experienced an amputation. Amber worried she’d have to quit her job to care for her husband. Through a Medicaid program, he receives in-home support services, which allows him to avoid a nursing home and her to return to work.

Another area ripe for reporting is the impact of Medicaid cuts on rural health systems, Park said. Rural hospitals are already in crisis, with many cutting staff and services or shuttering altogether. Reporters would be wise to look beyond the Medicaid populations to explore the broader ripple effects of hospital funding cuts on rural communities overall, he said. Rural hospitals and physician groups are often a leading employer in the community, and cuts to services and staff could have far broader social repercussions. 

Politico’s Ollstein suggested that fellow reporters turn a critical eye to Medicaid work requirements, which are likely to be included in any Republican bill. For example, reporters can investigate what happened in places such as Arkansas that did impose work requirements. How many people who work are disenrolled simply because they can’t navigate the bureaucratic hurdles of proving it? 

Said Ollstein: “The best time is now … now is the time to start reaching out to sources.”