Inside Trump's Tax And Spending Law: Medicaid Cuts & A 'Backdoor Abortion Ban'

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Hey there, it's the NPR Politics Podcast.

I'm Ashley Lopez.

I cover politics.

I'm Deirdre Walsh.

I cover Congress.

And NPR health correspondent Katia Riddle is here.

Welcome to the pod, Kadia.

Hi, thanks for having me.

And today we're taking a look at how the big tax cut and spending bill President Trump recently signed into law will affect health care.

Kadia, there's been a lot of focus on cuts and changes to Medicaid.

This is the government program that provides health insurance to people who are low income or have disabilities.

Can you tell me what exactly is happening to the program?

Yeah, so the Congressional Budget Office is saying that the cut will save close to $1 trillion.

And one of the primary ways they'll be realizing these savings is through increasing the demands around paperwork and the work requirements.

Most states will now require that people volunteer or work 80 hours a month.

Proving that can be onerous, though.

If you're balancing a bunch of different gig economy jobs, for example, it may be difficult to document the number of hours that you worked, especially if you just have to keep doing that frequently.

So if people fail to do that, then they will be kicked off the program.

So Katie, some states have already experimented with things like additional Medicaid work requirements and more paperwork.

How did those experiments fare in states that took them up?

Yeah, so as you've said, you know, this is an experiment that we've run before on a smaller scale in several states.

Arkansas and Georgia are two of the states that have tried this.

In both of those places, we've seen a lot of administrative hassle and confusion.

For example, in Arkansas, it was difficult just to

reach and find all the people that they needed to to inform them of these changes.

And then once they did find them, many people didn't have the computer literacy that they needed or the access to the internet in order to comply with the program and file all the paperwork that they needed to.

In Georgia, the program is ongoing, and it has ended up costing the state a lot of money, significantly more per patient than they were expecting.

And they've spent just more on administration than they have on health care.

Yeah, and I want to talk about how these cuts would affect health care in general.

We're talking about the Medicaid cuts here.

Like, how would this affect people who maybe aren't even part of that program?

Yeah, you know, the Biden administration really pumped a lot of money into the Affordable Care Act, health insurance, and it made it more affordable than it had been in the past.

So this law takes away that extra funding,

and it's also going to make it harder to actually get the insurance.

You know, people generally just don't like to think about their health insurance.

They want it to be there for them when they're sick.

By increasing the administrative burdens or increasing the price, that is just going to make it more difficult for people to get it and then to use it when they need it.

The CBO says millions of people as a result of these changes will lose their health insurance.

I think the other thing that's worth noting here, too,

is that Republicans structured this so that a lot of the changes to Medicaid, both to people who are eligible and the work requirements and the way states finance their own Medicaid programs in partnership with the federal government.

Medicaid is a state-federal partnership

and states rely on provider taxes to help them sort of

increase the amount of money they get from the federal government to cover Medicaid programs.

This issue, a lot of lawmakers worry, will have a particular impact on rural hospitals because those states rely more on the sort of existing system that helps those states get a certain amount of money from the federal government.

That's going to be cut because of the changes in this new law.

And although those don't go into effect until 2028, there is still some concerns about the financial viability of rural hospitals and what that means for anyone seeking care, right?

It's not just people on Medicaid that go to rural hospitals.

It's people on private insurance who can't drive a couple of hours to get to more urban medical centers.

Yeah.

I mean, and even though like the bulk of these cuts to Medicaid don't take effect for a little while,

we are already seeing Democrats, you know, starting to campaign on this issue.

Deirdre, what are you seeing so far from Democrats?

Right.

I mean, even before the votes on these bills, just throughout the debate, Democrats in both the House and the Senate were targeting Republicans who represent swing districts, Republicans in Senate races this year about the Republican bill

focusing on getting a lot of the savings from the Medicaid program and what that would mean for people in their districts.

And this week, we're starting to see some of the actual political ads.

Both the campaign arms for Democrats in the House and the Senate have released digital ads in the last couple of days that target Republicans who voted for these bills.

A lot of the ads in the House districts focused on lawmakers and the impact on rural hospitals.

Some of the Senate

focused ads are more on, you know, sort of numbers of people in those states that could be impacted by Medicaid.

And I think Republicans on the flip side are really trying to explain the benefits of the bill because so much of the debate was like, oh, the split inside the Republican Party on Medicaid.

And now I think they're trying to get out and educate people about, you know, the things in the bill like no tax on tips, no tax on overtime that will potentially boost certain people that supported Trump.

Yeah.

I wonder how effective that's going to be considering that more than 78 million Americans are enrolled in either Medicaid or CHIP, the children's health insurance programs.

I mean, how effective will that actually be for Republicans to sort of like the look over here approach?

Because this is a lot of Americans who could potentially be affected by these cuts.

I mean, I think it's kind of early to predict or to speculate, you know, how effective ads will be.

I mean, the midterm elections are not till November of 2026.

But I mean, I think you could look back at the 2018 midterm after Republicans had a trifecta and controlled both chambers of Congress and Trump was president, where there was an effort to repeal the Affordable Care Act.

Ultimately, it didn't pass, but

Democrats campaigned on that issue and won back control of the House.

All right, we're going to take a quick break.

More in a moment.

moment.

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And we're back.

Katia, one of the law's provisions specifically targets Planned Parenthood.

The organization just won a temporary injunction against that provision from taking effect for two weeks.

But can you explain to me what that provision does?

Yeah, so the law, it doesn't actually say the words Planned Parenthood, but it makes it illegal for states to make Medicaid payments to nonprofits that offer abortion and receive more than $800,000 in federal funding.

I want to lay this out clearly because it gets confusing.

It is already illegal to use federal funds to pay for abortions in all but a few extreme circumstances.

So what this provision does is it disallows for providers who offer abortion to take Medicaid for any reason.

Planned Parenthood has become known as a provider of abortion care, but it also provides a lot of other basic reproductive health care, things like cancer screening and birth control, STI testing.

So two things.

One, it threatens clinics that provide this basic care.

Many are in rural parts of the country.

Planned Parenthood is warning that 200 clinics across the country are now in jeopardy.

And two, by closing these clinics or potentially closing them, it ends access to abortion, even in states where the procedure is legal.

I spoke last week to an attorney for Planned Parenthood in Wisconsin.

There are 21 Planned Parenthood clinics across that state.

And she called this a, quote, backdoor abortion ban.

You know, in theory, Planned Parenthood could still receive Medicaid payments if it stopped providing abortion, but the organization has said vehemently that it will never stop.

Yeah.

I also want to talk about SNAP.

This is also one of the changes that Congress made.

This was the focus of some negotiations that ultimately helped get Alaska's Republican Senator Lisa Murkowski to vote for the bill.

Can you explain what changed as they got Murkowski on board?

So, like Medicaid, Republicans, in terms of trying to get some savings, added new work requirements to SNAP, requirements for people enrolled in the program to demonstrate that they're trying to get a job working

or in a job training program or educational program in order to qualify for the program.

Murkowski, who represents Alaska, made the case to Republican leaders really at the ninth hour, tenth hour, I don't know, the middle of night, whenever those negotiations took place, that Alaska has traditionally had a very high error rate in terms of SNAP people applying to the program, being in the program,

and that parents of children need to be in the program for older children, right?

Initially, the bill that came over from the House had a requirement that, you know, parents of young children were exempted from these requirements but once their kids got older they needed to meet these work requirements murkowski made the case that the age needed to be 14 and over she made the case that it's much harder for parents in alaska to have child care to be able to meet those work requirements.

So they changed the age, they changed the state requirements for what kind of paperwork they needed to be able to submit.

And it just shows you that how much, you know, the narrow concerns of one state's program can impact what's going to happen nationally.

Because by changing these and allowing a state with a higher error rate to still get some kind of carve out, it's almost an incentive for other states to not be as diligent about some of these paperwork requirements because they'll also just say we need more time.

And that sort of defeats the Republican aim in the bill, which was we're adding all these requirements to eliminate waste, fraud, and abuse to streamline the program for people who are most deserving of these federal assistance programs.

So the snap cuts work by changing the work requirements and eligibility for people to qualify.

One change specifically is around age.

It used to be that the work requirements applied to people 54 and younger, but they've changed that to 64 specifically for SNAP eligibility.

Yeah, so dear drew, I mean, you kind of got to this a little bit, but you know, President Trump has said that these cuts are about reducing waste, fraud, and abuse in these programs.

I mean, do you think this legislation is actually likely to accomplish that goal?

I mean, I think the reason why Republicans and the president keep focusing on that is because the president made a very specific campaign promise that no one was going to touch Medicaid, that people weren't going to be cut.

And they focus on the changes to the program being only waste, fraud, and abuse.

But as we've seen from the independent scorekeeper, the Congressional Budget Office, the changes to Medicaid are expected to generate nearly a trillion dollars in cuts.

That is more than you could get from waste, fraud, and abuse.

That is from what CBO says is an estimated 12 million people losing their health care coverage because of the changes in this bill.

So, you know, I think the other political argument that Republicans have been making about the changes to Medicaid, essentially financing the tax cuts in this bill, is that they are trying to focus on keeping Medicaid focused on the people that it was originally intended for, low-income, disabled, elderly.

But As we talked about earlier, when Obamacare passed, there was a huge increase to the numbers of people getting health care through Medicaid in the states and a lot of people like their health care the program is popular it's not just low-income elderly disabled it's a lot of you know people who can't get health insurance through their jobs and are getting it through state exchanges yeah different political matter giving benefits as opposed to taking it away Yeah, all right, let's leave it there for today.

Kadia, thanks so much for joining us today.

Thanks for having me.

I'm Ashley Lopez.

I cover politics.

I'm Deirdre Walsh.

I cover Congress.

And thank you for listening to the MPR Politics podcast.

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