Make America Uninsured Again

Yesterday's Senate vote to pass President Trump's legislative agenda means it's now in the House's hands and Senator John Fetterman can finally go.

I've missed our entire trip to the beach.

My family's going to be back.

It was a tight vote.

A lot to fight about in 900-plus pages, but the loudest fight was over Medicaid.

Trump's tax cuts had to be paid for, and the bill uses new work requirements and cuts to Medicaid to do that.

The Congressional Budget Office estimates around 12 million people could lose their health insurance in the next decade.

Ezra Klein is so mad, you guys.

When they get sick,

they will not be able to get chemotherapy or they will have to go into medical debt to get chemotherapy.

Like,

why?

So I can get a tax cut?

The fact is that in the 2024 election, President Trump got a huge share of the working class vote, so many of his voters risk losing their insurance now.

A thing that some Republicans had copped to, then voted for it anyway.

That's all ahead on Today Explained.

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The house will be in order.

The clerk may call the roll.

Today, yay.

Explained, yay.

I'm Noelle King with Burgess Everett.

He's the Congressional Bureau Chief for Semaphore Burgess.

900 plus pages.

What's in it?

Oh, boy,

it's hard to quantify, and that's a challenge we've all been dealing with as journalists because writers have to describe things quickly.

A lot of people are calling it a mega bill.

It's designed to extend the Trump tax cuts from 2017.

So that's the underpinning to the bill.

It also includes President Trump's tax promises or some version of them, which would be reducing taxes on overtime, on tips.

No tax on tips.

No tax on tips.

And on older Americans, they can't really do it for Social Security recipients, but they did kind of find a workaround.

From there, you had to find spending offsets because all that stuff costs trillions of dollars because they didn't just extend these tax cuts that are expiring, they made them permanent.

They also made these business tax cuts permanent.

That means permanently extending the lower tax rates.

permanently extending the increased standard deduction, and not only permanently extending the enhanced child tax credit, but enhancing it even further.

And so conservatives insisted on paying for some of this.

And the way they did that is essentially cutting Medicaid to the tune of nearly a trillion dollars overall, some of its work requirements, some of its cuts to this funding mechanism called the provider tax.

And then there was also a bunch of cuts to mostly President Biden's energy subsidies from the Inflation Reduction Act, which was passed in a similar fashion three years ago.

The thing that is making a lot of news, all of this is making a lot of news, but in particular, cuts to Medicaid, because many Americans will lose their health insurance.

What was the argument for making cuts to Medicaid and instituting work requirements?

Well, the work requirements piece, I think Republicans felt like that was the most defensible.

They've sort of created this image that everybody that's using the Affordable Care Act's Medicaid expansion,

a lot of people are able-bodied adults that are sitting at home and not working when they could be working.

So it's just leaning on that old chestnut that those, it's a bigoted chestnut, that those who receive Medicaid are in some ways unwilling to work, are in some ways lazy.

I'm sure that describes a certain amount of people doing it.

I'm sure there's lots of other people that are trying to work, finding jobs, having a hard time getting health insurance that are absolutely doing their best and not trying to be lazy.

So that's one piece of it.

The other piece is that these cuts don't go into effect right away.

So the Medicaid work requirements are fairly quick, but these other changes, they don't take effect for years.

And so I think one thing that I think people are missing is that I think a lot of these cuts are going to be delayed, delayed, delayed, especially if Democrats take charge either in 2026 or in 2028.

I think you'll see a lot of the big attempt on a lot of these things being reversed.

And look no further than Josh Hawley, the Missouri Republican, who said, in the same breath he said he was voting for this bill, said that he was going to do everything he could to keep the Medicaid cuts on the provider tax from going through.

All right.

So even after the passage, we've been reading about deep divisions.

Josh Hawley is a man divided against himself.

But which Republicans voted against this bill and why?

Three Republicans for three different reasons.

Most people know Susan Collins.

She's a moderate Republican.

She's up for re-election in 2026.

She hated the Medicaid cuts.

She liked the tax cuts.

Overall, she was trying to even raise taxes on the highest earners to pay for a larger hospital, they call it a stabilization fund.

It's really like a bailout for hospitals that are getting hurt by this bill in the future, rural hospitals specifically.

Our rural hospitals and nursing homes are under great financial strain right now.

That did not pass.

I think if it had passed, she might have entertained voting for the bill because that would have also raised money.

And we were talking 25 million, people who earn 25, $50 million a year are like really high earners.

Other person's Tom Tillis in that bucket.

He was so stressed by this entire episode, he announced his retirement in the middle of it on Sunday.

He did not like the Medicaid cuts.

What do I tell 663,000 people in two years or three years when President Trump breaks his promise by pushing them off of Medicaid.

So President Trump started attacking him.

He just had enough and quit on Sunday and said, I'm not running for reelection.

I've never seen somebody denounce their retirement in the middle of something like this.

The third one is Rand Paul from Kentucky, kind of this purist, libertarian-leaning Republican.

He was actually in play at the end.

Republicans were trying to choose kind of which path do we take.

Do we try to get Lisa Murkowski, give her a lot of Alaska-specific things, or do we go to Rand Paul, who wanted a much lower debt ceiling increase?

But the main thing that I object to is raising the debt ceiling four or five trillion dollars.

Ultimately, leadership wanted to work with Murkowski more and found that deal better.

But Rand Paul was in play right up until the end.

Some people are saying that Senator John Thune is a big part of how this got done.

You interviewed him yesterday.

What did you find from him?

The thing about Jon Thune that people should know, he's not a household name.

I don't know if he'll ever be.

Sometimes you're a majority leader and you become just a villain or a hero to the people in your party.

I think Mitch McConnell at times was a hero for Republicans and at other times was a villain.

Jon Thune is probably more physically conservative than Mitch McConnell, but his demeanor is very Midwestern.

He's from South Dakota.

And I want to start by thanking the staff on the committees, the relevant committees, the floor staff.

He's super nice and personable.

Not to make myself part of the story, but he was probably the first senator, along with Senator Schumer, to learn my name in covering Capitol Hill, which is the kind of thing you remember when you have no idea what you're doing at the start of your career.

And Senator Thune wrote a...

more conservative bill, I think, than a lot of his members thought that was going to happen.

They thought he was going to essentially copy the framework of the House and be more gentle on the Inflation Reduction Act tax credits and be more gentle on Medicaid.

And he went the opposite way.

He stuck with it.

He just kept pushing forward and he eventually paid off.

It's a big political risk.

It could certainly put his majority in play, if not in 2026, and certainly in 2028.

But he really believed in the policy.

And I think it's a testament to the fact he was able to get this done on a totally artificial deadline.

That his leadership style was somewhat vindicated, I think, by this whole episode.

Even as messy as it was, the results are going to be what's remembered.

How does Thune answer those hard questions about we're increasing the national debt, we're raising the deficit?

These are not typically Republican priorities.

Well, if you look at history, Republicans are much more deficit hawks when they're in the minority and when there's a Democrat president than when they're in power.

I think he would argue this bill's,

all the scores and the estimates of this don't capture the growth that'll come from this bill.

It's an argument that Republicans have made for a long time.

I can't say whether he's right or not, but I do think that if you look at the nonpartisan scorekeeper from Congress that both parties are supposed to rely on, the Congressional Budget Office, they say this bill is going to explode the deficit, mostly from extending those tax cuts, especially permanently and not really paying for them.

All right.

So the bill is likely to become law.

And then the risk is, as you've alluded to, the bill could become a nightmare for the GOP.

Americans losing their health insurance, realizing wealthy people got tax breaks that they didn't.

Many of these Americans voted for President Trump.

His base shifted in the last election to include many more working class people.

How does the party mitigate

these kinds of risks?

It's likely to be a political loser in the short term.

Perhaps it's not in the long term.

The Republicans are betting that the tax cuts, which go into effect quickly, are going to be seen by people

a lot more vividly than these future cuts to Medicaid program.

We'll see if they're right.

I think the 2026 election, if Democrats are able to frame it the right way, could be simply about Medicaid cuts versus tax cuts.

And I'm not sure that Republicans are going to win that argument in the short term.

I think it's going to be really challenging.

And I think they know that.

You see the polling for this bill.

It's not great.

So, now, can they put their money where their mouth is, spend a lot of ads on this, and get people to believe it's a good bill?

It's certainly possible.

But most of the time, the majority party pays a little bit of a political price after passing a big piece of legislation like this.

You don't have to go back too far.

The passage of the Affordable Care Act was dogging Democrats for years and years.

Burgess Everett of Semaphore, coming up the millions of people who could lose their health insurance as a result of this bill.

Like,

why?

So I can get a tax cut?

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Jonathan Chait is a writer for The Atlantic.

Jonathan, you recently wrote for The Atlantic that the Republican Party is engaging in magical thinking around Medicaid.

What did you mean?

Well, you have different people within the Republican Party.

You have people who are not straightforwardly arguing that they are trying to reduce the Medicaid roles and push people off the program.

We're trying to make structural reforms that make these programs stronger and make them be able to actually last and be there for the people who need that assistance.

We want these to be, we want them to be safety nuts, not hammocks.

There are no Medicaid cuts in the Big Beautiful bill.

We're not cutting Medicaid.

What we're doing is strengthening the program.

We're reducing fraud, waste, and abuse that is rampant in Medicaid.

They are not eligible, so they will be coming off.

So

people are not dying.

Well, we all are going to die.

Even though that is the obvious and unavoidable effect of the policies that they're enacting.

And the reason for that is that Medicaid is very popular, including among their own base.

Republicans themselves, that is, Republican voters, don't want to cut the Medicaid program.

And Donald Trump has attracted a lot of people who are on Medicaid into the Republican coalition.

So it's a very politically dangerous move for them to make to cut Medicaid.

Nonetheless, Republican elected officials and other elites in the Republican Party have always hated Medicaid, have always hated social insurance programs in general, and wished that they could cut them.

The sad truth is that our welfare system represents one long and sorry tale of disappointment.

So So Medicaid, sending it back to the states, capping its growth rate.

We've been dreaming of this since I've been around, since you and I were drinking out of keg.

So their solution to this dilemma of being caught between the desires of their own voters and what their own elected officials want is to simply pretend that they're not doing what they're actually doing.

Steve Bannon, the White House advisor, has warned the administration against cutting Medicaid, saying a lot of MAGAs are on Medicaid.

They don't want to be on Medicaid, but they're on Medicaid.

You can't be cutting that until you get to the defense about it.

You got to get across the Potomac, you got to face facts, you got to face a hard reality.

One of the ways that American politics has changed over the past 10, 20 years, and especially accelerated in the Trump era, is that Republicans have won over higher numbers of low-income people under their coalition.

And an effect of that is that a pretty large percentage of people who are on Medicaid voted for Donald Trump in the last election and stand to lose.

And that's reflected in the polling.

Republicans do not want to cut Medicaid.

The big majority of working class voters voted for the GOP.

That means now the GOP needs to deliver for them.

And we do that by giving them tax relief.

We do that by bringing down their health care bills.

We don't do it by cutting Medicaid.

It used to be 20 or 30 years ago a program that Republicans felt at least a little bit safe going after because they saw it as benefiting Democrats and not benefiting them.

But that's not not the case anymore.

So it's really a program that covers not only a lot of Americans, but also a lot of Trump voters.

There are Republican senators who appear to understand this.

Tom Tillis of North Carolina announced he's not going to run for reelection.

He cited his frustration with Medicaid cuts.

Republicans are about to make a mistake on health care and betraying a promise.

Josh Hawley is another one.

He's been speaking on behalf of one of his constituents who's a mother of five children, one of whom is very sick.

And it's just wrong to go and cut their health care when they're trying to make ends meet, trying to help their kids.

We cannot let people like my daughter lose her benefits.

And if anybody tells you that, oh,

she's covered, she's protected, I would really encourage you to say how.

Josh Hawley ultimately voted for this thing, but why are there not more and louder voices in the party?

Why is it only a handful of Republicans who seem to understand this is existential?

These are our constituents who voted us into office.

I think it's a combination of them not really understanding how the changes work and kind of falling for the Republican spin that they're not really throwing people off the program.

And some of them know what they're doing and support it.

You have a really long tradition in the Republican Party of rejecting the welfare state, believing that giving people access to health care is not the government's job.

It's now common knowledge that our welfare system has itself become a poverty trap, a creator and reinforcer of dependency.

That if you want to get health care, you should pick yourself up by your bootstraps and get yourself a job that provides health insurance.

That it's not the government's role to make sure that people can go to the doctor and get medicine.

That's their own responsibility.

And they see this as an opportunity to make that vision closer to reality.

So the Senate bill is going to place work requirements on Medicaid recipients.

Arkansas experimented with this in 2018.

How did that experiment turn out?

What happened?

What happened was the work requirements were incredibly onerous for people to get through.

I thought that everything was good about this.

I thought it was just a one-time deal that you reported and then

that was it.

It's very cumbersome to get into certain areas of the website and sometimes it's not even working working because they do a lot of updates.

You had to

file paperwork with the government every month proving that you were working or you were looking for work or going to school or doing a list of activities that made you eligible for Medicaid.

And

this required going through a website or a phone system that was hard to work, that was hard to reach, it was often down, it was unavailable, or people couldn't get the information they needed to verify what they were trying to file for the government.

It was sort of like filing a tax return when you're being audited by the IRS, but you have to do it every single month.

Just incredibly difficult process for people to go through.

So what happened was lots of people who were actually supposed to be eligible for Medicaid lost their eligibility because they couldn't get through the paperwork requirements or they couldn't get into the system, into the phone system or into the web system.

So just thousands and thousands of people lost their health insurance, couldn't go to the doctor, or they'd show up at the doctor and they'd learn that the doctor

wouldn't take their Medicaid because they weren't on the program anymore.

So

it was a real social disaster.

In Arkansas, early implementation of work requirements led to 18,000 people losing their health insurance.

The federal judge has struck down the work requirements for Arkansas's Medicaid beneficiaries.

All right, so Arkansas turned into a social disaster.

Georgia also experimented with work requirements.

What happened there?

It was basically even worse.

It was the same thing all over again.

The work requirements were just as difficult to get through, if not more so.

You had thousands and thousands of people losing their health insurance, people who were eligible.

And

researchers who looked at both states found it did not promote work at all.

That the stated intent of this policy was to encourage people to get a job who were unwilling to work by threatening but to take away their Medicaid if they didn't, but it did absolutely nothing to encourage employment.

In fact, reporters found some examples of the opposite happening.

They found people who

were working, were on Medicaid, lost their Medicaid because they couldn't get through the paperwork requirements, got sick,

couldn't work as a result of getting sick,

and didn't have treatment through Medicaid, and now were physically unable to work.

Are our leading Republicans, the ones speaking out in favor of Medicaid cuts, are they aware of what happened in Georgia and Arkansas?

That's a really good question.

Yeah.

You know, I haven't seen anyone on the right engaging with what happened in Arkansas and Georgia anyway.

I can't prove it doesn't exist because you can't prove a negative.

But I've actually been fascinated by that same question.

Why are they replicating a policy that has failed so clearly by its own standards?

And I read conservative media a lot.

I read it every single day.

I haven't seen a single reference to the way this program operated in those states that tried to explain why it was a success.

They just insist that it's going to do what they say it'll do.

They just say it's what's wrong with making people work to get their Medicaid and

going on as if it will obviously work the way it's supposed to.

So yeah,

it's very puzzling.

President Trump sat in the Oval Office in May and he said, casually, but it seemed sincerely that maybe rich Americans should pay a little bit more in taxes.

This bill, in various ways, including the cuts to Medicaid, does exactly the opposite of that.

Do you think that Donald Trump wants to do things for this new low-income base that helped vote him into office?

in 2024?

I think Donald Trump is much less committed to policy goals than Republicans Republicans in Congress are.

He cares a lot more about being popular.

And so for that reason, I think he's willing to compromise on policy goals in order to do the popular thing.

But I think he cares most about just getting this bill passed.

And Republicans don't want to raise taxes on the rich.

They believe with religious fervor that raising taxes on the rich is a sin, is immoral.

And they refuse to do it.

And I think Donald Trump has recognized that, and he recognizes that he's not going to pass anything through Congress if it raises taxes on the rich and he cares about passing something.

So he's abandoned that goal.

If this bill does pass the House, if these cuts to Medicaid go through, what happens next?

What happens next is that you'll get cascading effects to people's health insurance and to the financial well-being of a lot of hospitals, especially rural ones.

Rural hospitals are in much worse shape than urban hospitals,

although there are hospitals that are struggling all around the country.

And if the hospitals lose millions of paying customers who can no longer reimburse them for health care, those hospitals are going to be in bad shape.

And roughly 12 million people are slated to lose their health insurance as a result of this bill.

So this would be an absolutely gigantic rollback

in health coverage and public health in the United States.

Really, something that's totally unprecedented.

Jonathan Chait of The Atlantic.

He's been writing about Medicaid.

Denise Guerra produced today's show.

Amina El Sadi edited.

Laura Bullard checks the facts.

Andrea Christen's daughter and Patrick Boyd engineered.

And I am Noelle King, and this is Today Explained.

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