Originally published in The Hastings Bioethic Forum on May 23, 2025.
The budget bill adopted by the House of Representatives on May 22 is not so much a fiscal blueprint as a manifesto in policy retrenchment. Behind its rhetoric of “restraint” lies a dramatic reordering of national health priorities—chief among them, an aggressive rollback of Medicaid coverage and an erosion of the Affordable Care Act. It is a return to the failed “Repeal and Replace” effort of 2017, now being sold as an exercise in fiscal restraint.
To pay for the $3.8 trillion in tax cuts for the wealthy, the bill includes $792 billion in cuts to Medicaid. Of that, $360 billion targets the ACA’s Medicaid expansion—disenfranchising an estimated 7.6 million beneficiaries.
One mechanism used by the bill involves work requirements for Medicaid clients. Earlier versions would have rolled these requirements out in 2029, but the timeline for imposing them has been advanced to the end of 2026, at the urging of the Freedom Caucus. That single maneuver would account for $280 billion in projected “savings.” Another $165 billion would be achieved by delaying eligibility rules that had been issued by the Centers for Medicare and Medicaid services. These rules were designed to streamline the application and enrollment processes in Medicaid.