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The Republican plan to save $715 billion in Medicaid spending centers largely on cutting benefits to people ages 19 to 64 who are unemployed and those living illegally in the U.S.
Under the plan to cut taxes and reduce federal spending, roughly 4.8 million able-bodied adults would no longer have access to Medicaid, the nation’s health care program for the poor.
The Republicans’ “big, beautiful bill” under consideration in the House would save billions of dollars more by cutting off Medicaid benefits to 1.4 million illegal immigrants.
“Our plan will ensure that Medicaid benefits are there for those who need them most,” said House Energy and Commerce Committee Chairman Brett Guthrie, Kentucky Republican. “Not illegal immigrants, ineligible recipients and those choosing not to work.”
Unlike the nation’s food stamp program and other welfare benefits, Medicaid for able-bodied, childless adults has never included a work requirement.
The Republican plan would require these Medicaid recipients to work, provide community service or attend training for 80 hours monthly. The Medicaid proposal aligns with the requirements for access to the Supplemental Nutrition Assistance Program, commonly known as food stamps.
The Congressional Budget Office estimated that nearly 5 million people could lose Medicaid benefits because of work requirements.
“Many have argued work requirements should be a condition for all of our welfare programs, and Medicaid is a welfare program,” said Nina Owcharenko Schaefer, director of the Center for Health and Welfare Policy at the conservative Heritage Foundation. “Our goal should not be to have you stay on welfare for your whole life. You want to help people out of poverty and get them into the workforce so that they can get a stable job and continue.”
Medicaid is the nation’s fastest-growing entitlement program. The Republicans’ proposal to cull recipients has left them politically vulnerable to Democratic accusations that it would leave the sickest and poorest people in the nation without health care.
The cuts are part of a Republican effort to slash at least $1.5 trillion in federal spending in exchange for permanently extending Mr. Trump’s 2017 tax cuts for individuals and providing additional tax breaks on overtime pay, tips, auto loan interest and Social Security for seniors.
The Congressional Budget Office said the work requirements provide the most significant savings in Medicaid spending, amounting to more than $300 billion over 10 years.
Critics say the Medicaid reforms do not consider a swath of vulnerable recipients who don’t work but desperately need health care.
Nonworking Medicaid recipients include people with substance abuse problems or mental illness who may have difficulty qualifying for work exemptions.
In 2023, more than 15% of unemployed Americans suffered from both mental illness and drug addiction, according to data from the Substance Abuse and Mental Health Services Administration.
Democrats said the proposed requirements would cut coverage for millions who could not navigate the steps and paperwork requirements to qualify.
They said cuts to Medicaid would shutter rural hospitals and nursing homes that rely on Medicaid patients and reverse efforts to expand access to health care.
“We’ve been moving toward getting to a place where every single American can have access to the health care that they need to live a life of dignity and respect,” said House Minority Leader Hakeem Jeffries, New York Democrat. “Unfortunately, House Republicans, Senate Republicans and the Trump administration are undermining the progress that has been made in the area of health care, and are now putting access to health care at risk for millions of people all across this country.”
Mr. Jeffries warned that “people will die” under the proposed cuts.
Amid negative media coverage and political attacks on the plan, President Trump rushed to Capitol Hill on Tuesday to assuage wary Republican lawmakers. He stopped in the hallway to defend the Medicaid reductions.
“The only thing we are cutting is waste, fraud and abuse,” Mr. Trump told reporters.
The president said, “We have illegal aliens that are multiple killers with multiple murder records” receiving benefits under the current Medicaid program.
“I don’t think anybody minds that we cut that,” he said.
Illegal immigrants are ineligible for Medicaid, but authors of the Republican proposal say many are fraudulently enrolled.
“We are going after the 1.4 million that should not be in the program,” said a top aide on the House Ways and Means Committee.
The bill would also target 14 states and the District of Columbia that provide health care coverage to illegal immigrants using their own pots of funding.
It would reduce the federal matching rate for Medicaid expansion provided under the Affordable Care Act. The federal government now pays 90% of the costs to Medicaid enrollees covered under the act. Unless the states drop health care coverage to illegal immigrants, their match would fall to 80% beginning in October 2027.
Other cuts would stop duplicative coverage to thousands of people enrolled in Medicaid in more than one state.
A federal analysis found an extensive problem. In 2019 alone, nearly $73 million in improper payments went to beneficiaries enrolled in Medicaid in multiple states.
The federal government is estimated to be funding 1.6 million people who are enrolled in two different states.
“That is fraud,” said Rep. Julie Fedorchak, North Dakota Republican.
The legislation would remove 1.2 million who are ineligible because of their income levels and other factors. The growth in Medicaid enrollment would be reduced by an estimated 200,000 people.
Republicans said Medicaid reform would save the program for people it was designed to serve: disabled Americans, impoverished seniors and pregnant women. The Medicaid program would continue to grow under the Republican plan and increase by 25% over the next decade.
“Only in Washington is a spending increase labeled a cut,” Ms. Fedorchak said.
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