Following a series of middle-of-the-night backroom deals, and less than an hour after the final language was unveiled, Senate Republicans voted to pass a bill that would raise food and health care costs on families, increase poverty and hunger, and take health coverage away from millions of people while doubling down on costly tax cuts for the wealthy and corporations.

The Senate Republican bill’s federal Medicaid cuts are even deeper than the massive House cuts, making it more likely that states would cut their programs and putting rural hospitals and other community health providers at even greater long-term risk of closure.

House Republicans, many of whom looked to the Senate to craft a bill that was less damaging than the House bill, must stand up for their communities and reject it.

The more people have learned about the bill, the more opposition has grown. Now we will learn whether House Republicans, with time to reflect on the damage this agenda would cause and the ways the Senate made the bill worse, are as thoughtful as the people they serve.

Just days ago, some House Republicans expressed opposition to the additional Medicaid cuts the Senate was considering. Those additional cuts are in the Senate Republican bill that the House is expected to vote on as soon as tomorrow.

The Senate Republican bill would cut Medicaid by nearly $1 trillion, compared to $800 billion in the House Republican bill. The deeper cuts translate into larger harmful impacts.

The bill also would expand the House Republican bill’s provision that takes Medicaid coverage away from people who don’t meet a red-tape-laden work requirement by applying it to parents enrolled through the Medicaid expansion who have children older than 13.

Working parents who get tripped up by red tape, parents who get laid off and are looking for work, parents who lose their jobs when they get sick or need to care for a sick child — as well as adults without children who have disabilities, are between jobs, or are working — would lose access to the health care they need to work, to care for their children, and to beat treatable illnesses.

Relative to the House Republican bill, the Senate version would make it even harder for some states to finance their Medicaid programs. Senate Republicans know the bill would hurt rural hospitals — that’s why they added a face-saving temporary fund, but it won’t rescue rural providers when the funding runs dry and the permanent cuts to Medicaid and Affordable Care Act (ACA) marketplace coverage remain. This is particularly true because the revised Senate fund gives the Health and Human Services secretary significant discretion in how the funds would be allocated. Rural providers need people in their communities to have health coverage they can count on. Without that, more rural hospitals will close and more people with and without coverage will be cut off from care they need.

The Senate Republican bill also would take health coverage away from even more immigrants living and working in the U.S. lawfully than the House bill would. The Senate bill would take away federal funding of Medicaid and Children’s Health Insurance Program coverage for refugees, people granted asylum, certain victims of sex or labor trafficking, and certain victims of domestic violence, among others. This ban includes children, and as in the House bill, it also would take away Medicare, ACA premium tax credits, and food assistance through SNAP from these groups. Despite countless misleading statements, immigrants in the country without a documented status are already ineligible for all of these programs; everyone who would lose health coverage and food assistance because of this bill is living lawfully in the U.S. (One anti-immigrant health provision in the House bill was not included due to a parliamentarian ruling.)

The Senate Republican bill would also raise families’ grocery costs, taking food assistance away from millions of people, including children and veterans, and forcing unaffordable costs on states. When states can’t pay those costs, they would be left with two choices — take SNAP benefits away from large numbers of people or end their SNAP programs entirely.

Again, it is clear that at least some Senate Republicans understand how damaging the provision is — they created a preposterous carve out to delay implementation of the cost-shift for states with the highest error rates in the country as a way to secure the votes they needed. But delaying for a handful of states a harmful provision that could unravel our most important anti-hunger program as a national program would not undo its damage.

Even as the Senate Republican bill would make deeper health care cuts, it continues the House’s approach of large tax cuts for the wealthy, including raising the amount heirs can inherit tax free from the largest estates to $30 million per couple and extending a deduction for business owners that would deliver more than half its benefits to millionaires.

The Senate bill would cost about $3.3 trillion when you remove the gimmick of assuming it is free to extend tax cuts. That is basically the same cost as extending all of the 2017 tax law’s expiring tax cuts for families — including millionaires — without any cuts to Medicaid and SNAP.

House Republicans should step back and find the courage to say no to any bill that would raise costs and take health coverage and food assistance away from people struggling to afford the basics — all while making deficits and debt soar and exposing our economy to more long-term risk.

But at the very least, as House Republican leaders seek to jam the Senate bill through the House, concerned House Republicans should follow through on their promise not to support a final bill that threatens access to Medicaid coverage and reject it.

If they don’t, they, along with their Senate counterparts, will own its impacts. Unfortunately, it is their constituents who will pay the price for their poor leadership.

WASHINGTON — The Republican-controlled House passed a multitrillion-dollar package of tax cuts and spending Thursday, sending it to President Donald Trump’s desk after a tense 24 hours of negotiations and arm-twisting.

The mostly party-line vote of 218-214, which came one day ahead of Trump’s July 4 deadline, caps an arduous process that lasted more than four months, rife with ideological clashes and acrimony between the House and the Senate, where Republicans had little margin for error given their narrow majorities.

In the end, the GOP largely unified to pack the bulk of Trump’s domestic agenda into a single measure, with just Reps. Thomas Massie of Kentucky and Brian Fitzpatrick of Pennsylvania voting against it. A bloc of Republican holdouts had initially opposed a procedural vote Wednesday to advance the bill, leading to an hourslong overnight standoff. But Trump and Speaker Mike Johnson, R-La., managed to sway all but one of them, teeing up final passage in the House.

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Trump is expected to sign the bill into law on Independence Day, marking the party’s biggest legislative accomplishment since it took full control of Washington in January.

Trump applauded Republicans after the bill passed Thursday, writing on Truth Social that the successful effort signaled a united Republican Party.

“The Republicans in the House of Representatives have just passed the ‘ONE BIG BEAUTIFUL BILL ACT.’ Our Party is UNITED like never before and, our Country is ‘HOT.’ We are going to have a Signing Celebration at the White House,” he wrote. “All Congressmen/women and Senators are invited.”

Trump continued the praise Thursday evening at an event in Des Moines, Iowa, organized to celebrate Independence Day.

“There could be no better birthday present for America than the phenomenal victory we achieved just hours ago when Congress passed the One Big Beautiful Bill to make America great again,” he said, lauding the legislation as “a declaration of independence from a national decline.”

The 887-page package, dubbed the “one big, beautiful bill,” extends the tax cuts Trump enacted in 2017 while temporarily slashing taxes on tips and overtime pay. It approves hundreds of billions of dollars in new spending on the military and on carrying out Trump’s mass deportation plans. And it partly pays for all that with steep cuts to Medicaid, food aid benefits and clean energy funding. That includes an estimated $930 billion in spending reductions under Medicaid, violating Trump’s promise not to cut the program.

Overall, the bill is projected to increase the national debt by $3.3 trillion over a decade, with the nonpartisan Congressional Budget Office finding that the revenue losses of $4.5 trillion outstrip the spending cuts of $1.2 trillion. The bill also increases the debt ceiling by $5 trillion.

Republican leaders celebrate

Throughout the process, Republican leaders had an ace in the hole to corral the votes even as the competing demands of rival factions appeared irreconcilable: They knew their members wouldn’t ultimately say no to Trump, from the most conservative to the least ideological and politically vulnerable.

“Republicans in Congress have succeeded in our mission to enact President Trump’s America First agenda,” Johnson said in joint statement with his leadership team. “And importantly, we did it in record time, so that the effects of this nation-shaping legislation can be felt by the American people as soon as possible.”

Republicans often turned to Trump throughout the process to help close the deal on key votes. He regularly held meetings with and made phone calls to key lawmakers while issuing the occasional threat on Truth Social to holdouts who stood in the bill’s way. Vice President JD Vance was also a regular presence in Senate and House meetings about the bill.

“If President Trump and Vice President Vance had not engaged at the time they did, it wouldn’t have passed,” said conservative Rep. Tim Burchett, R-Tenn., who attended White House meetings in the Oval Office and the Cabinet Room on Wednesday and ultimately voted for the bill.

Speaking to reporters in the wee hours of the morning, Johnson said Trump had been making phone calls to recalcitrant holdouts as late as 1 a.m. Thursday to help break an impasse on the floor.

“He doesn’t really sleep a lot,” said Johnson, who also dangled the prospect of future bills to address concerns and demands from a variety of members.

In his 1 a.m. call with holdouts, Trump and other White House officials promised to aggressively implement key provisions in the bill — from clean energy tax credit phaseouts to new Medicaid restrictions, a source familiar with the call said.

One by one, the GOP critics folded and accepted demands they insisted they wouldn’t. Conservatives swallowed a bill that adds trillions to the debt. Politically vulnerable Republicans endorsed steep cuts to Medicaid and health care spending that the CBO projects will cost 11.8 million people their insurance. Republicans whose districts and states benefit from clean energy incentives ended up voting to strip them away.

“They’re just afraid of Trump and the backlash that would ensue if he called them out,” Massie, who opposed the bill, told NBC News the day before the final vote. “I’m not concerned.”

Trump told reporters Thursday that it was “easy” to get skeptical Republicans on board during his conversations and said he didn’t offer any lawmakers specific commitments or promises.

“I did not have much of a problem with any of them,” he said. “No deals. What I did is we talked about how good the bill is.”

GOP holdouts fold after threats to vote no

Rep. David Valadao, R-Calif., led a June 24 letter from 16 Republicans vowing to oppose the Senate bill because of its Medicaid cuts, which were more aggressive than those in an earlier bill. They warned that the bill would impose “penalties” for states with larger programs, “cuts to emergency Medicaid funding” and “additional burdens on hospitals already stretched thin.”

“Protecting Medicaid is essential for the vulnerable constituents we were elected to represent. Therefore, we cannot support a final bill that threatens access to coverage or jeopardizes the stability of our hospitals and providers,” they wrote.

The following week, all 16 of them voted for the bill anyway. Valadao’s office didn’t reply to requests for comment.

Trump and his allies sought to strike fear in GOP lawmakers by vowing to support a primary challenger to Massie in his next election. Massie, who objected to the large deficit increase in the bill, said Trump’s real goal was to keep other Republicans in line by sending a message that defying him comes with political pain.

“They’re whipping this horse, because I’m out of the barn, to keep the other horses in the barn,” he said.

Fitzpatrick, who represents a swing district, said the steeper Medicaid cuts, “in addition to several other Senate provisions,” moved him from supporting an earlier version of the bill to opposing the final one.

“I believe in, and will always fight for, policies that are thoughtful, compassionate, and good for our community,” he said in a statement. “It is this standard that will always guide my legislative decisions.”

Later, on the 1 a.m. call with Trump, Massie remarked that it would be nice if Trump stopped attacking him, the source said, then flipped from no to yes on the key procedural vote.

Trump said Thursday that he was “disappointed” that Fitzpatrick voted against the bill but stopped short of backing a primary challenge against him.

Democrats slam the bill as ‘disgusting’

The House took up the bill after the Senate voted 51-50 to pass it on Tuesday, with Vance breaking the tie. The only Republicans who voted against it were Rand Paul of Kentucky, Thom Tillis of North Carolina and Susan Collins of Maine. The party used the filibuster-proof “budget reconciliation” process to get around the 60-vote threshold, which meant some non-budgetary provisions were stripped out.

Every Democrat in both chambers voted against the bill, blasting it as a tax cut for the wealthy that is paid for by cutting programs that benefit the working class, like Medicaid. They plan to place a heavy focus on the bill in their message to voters ahead of the 2026 midterm elections, emboldened by polls showing that the legislation is unpopular.

At the start of a record-breaking floor speech Thursday morning that lasted for 8 hours and 44 minutes, House Minority Leader Hakeem Jeffries, D-N.Y., ripped what he called the “big, ugly bill, this disgusting abomination,” and accused Republicans of working through the night to pass it because it would kick millions of people off Medicaid and food stamps. Republicans argued that work requirements would target waste, fraud and abuse in those programs.

“Why did debate begin at 3:28 a.m. in the morning?” Jeffries asked with House Democrats filling the seats behind him. “Republicans are once again, which has been the case, Mr. Speaker, through every step of this journey, trying to jam this bill through the House of Representatives under cover of darkness.”

Trump decried Democratic opposition in his remarks in Iowa, bluntly telling supporters that he “hates” Democrats.

“They wouldn’t vote only because they hate Trump, but I hate them, too, you know?” he said. “I really do. I hate them. I cannot stand them, because I really believe they hate our country.”

Republicans began making plans for their reconciliation package even before last year’s presidential election. In March 2024, House Republicans huddled at their annual retreat, at the Greenbrier Resort in West Virginia, to brainstorm what should be in the bill so they’d be better prepared than in 2017.

But after Republicans took unified control of the White House and Congress in January, fissures in the party quickly began to emerge. Senate leaders pushed to carry out Trump’s agenda in two separate bills, before he endorsed the House approach of passing his agenda in “one big, beautiful bill,” which eventually became the title of the legislation.

Along the way, all 53 Senate Republicans voted to set a novel precedent by using a budget trick known as “current policy baseline,” which treats $3.8 trillion in Trump tax cut extensions as costing $0, to avoid satisfying Senate rules requiring that they be paid for. Democrats said it was akin to the “nuclear option” and that it will weaken the 60-vote threshold going forward.

Still, Democrats did get in a jab at Trump in the process: They deleted the title, “One Big Beautiful Bill Act,” by successfully arguing that the name wasn’t budgetary in nature. The legislation’s official title is, instead, “An Act to provide for reconciliation pursuant to title II of H. Con. Res. 14.”

Here’s what’s in the GOP megabill that’s just passed the House

toggle caption Kevin Dietsch/Getty Images

House Republicans have passed their massive bill to enact the heart of President Trump’s domestic agenda, overcoming deep divisions inside the party to advance legislation that would cut trillions of dollars in taxes while scaling back safety net programs such as Medicaid and SNAP.

The final vote was 215-214.

“Today the House has passed generational, truly nation-shaping legislation to reduce spending and permanently lower taxes for families and job creators, secure the border, unleash American energy dominance, restore peace through strength and make government work more efficiently and effectively for all Americans,” House Speaker Mike Johnson, R-La., said after the vote. “House Democrats voted against all of that.”

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The legislation aims to satisfy competing demands from fiscal hawks looking to reduce the deficit to blue state Republicans looking to lock in more favorable taxes for their constituents.

The Thursday vote followed a day of near-constant negotiations within the GOP. The talks included a White House meeting between Trump, Johnson and several holdouts and skeptics.

Trump celebrated the vote in a Thursday morning post on his social media site, Truth Social.

“This is arguably the most significant piece of Legislation that will ever be signed in the History of our Country!” Trump wrote before detailing some of elements of the bill. “Great job by Speaker Mike Johnson, and the House Leadership, and thank you to every Republican who voted YES on this Historic Bill! Now, it’s time for our friends in the United States Senate to get to work, and send this Bill to my desk AS SOON AS POSSIBLE! There is no time to waste.”

Johnson entered the vote needing near unanimous support from his members for the bill to pass. House passage is one step in a lengthy process. Republicans still face more challenges in the Senate where lawmakers have already signaled reservations about key elements of the plan.

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The sweeping piece of legislation runs more than 1,000 pages long. Here’s a brief look at some of the key elements inside the latest version:

Extending the Trump tax cuts

The Republican plan calls for roughly $3.8 trillion in tax cuts — the bulk of which would come by extending the 2017 Trump tax cuts. Those cuts are due to expire at the end of the year, so without an extension, most households would see their taxes go up.

No taxes on tips or overtime

The bill includes temporary changes designed to make good on several of Trump’s campaign pledges, including no taxes on overtime earned between 2026 and 2028. The plan would also allow Americans to deduct interest on car loans — but only if the car is made in the U.S. It would increase the child tax credit to $2,500 until 2028 — but only for people with Social Security numbers. After that, it would drop to $2,000 and grow with inflation. It would allow for a higher standard deduction through 2028, and to deliver on Trump’s pledge not to tax Social Security benefits, the bill would allow for an extra $4,000 deduction for people over the age of 65, but it phases out for people at higher incomes.

More SALT

One of the thorniest issues during negotiations has been the state and local tax deduction, also known as SALT. The deduction is hugely important to a small number of GOP lawmakers from blue states with high taxes, such as California and New York. The 2017 tax cuts capped the SALT deduction at $10,000. The House plan would lift the cap to $40,000 for married couples with incomes up to $500,000.

Work requirements for Medicaid

The bill includes several proposed changes to Medicaid — the joint federal/state health care program for low-income, elderly and disabled Americans. It has remained one of the most divisive issues throughout GOP negotiations, but lawmakers argue that changes introduced by the bill will bring in hundreds of billions in necessary savings through the introduction of new work requirements. Beginning at the end of 2026, childless adults without disabilities would be required to work 80 hours per month to qualify for benefits.

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The legislation also zeroes in on what Republicans characterize as “waste fraud and abuse” within the program by shifting the enrollment period from once a year to every six months and adding additional income and residency verifications for enrolled individuals.

Changes to SNAP

The Republican legislation also outlines reforms for the Supplemental Nutrition Assistance Program, known as SNAP, which benefits more than 40 million low-income Americans. The bill increases the amount states contribute to the program and mandates work requirements for able-bodied SNAP enrollees who don’t have dependents. Independent estimates suggest these changes could result in many people losing coverage. Like with Medicaid talks, some Republican lawmakers have pushed back against massive changes to SNAP given its wide reach and the millions enrolled in the program.

Lift the debt ceiling

The House bill would raise the nation’s debt limit by $4 trillion. Lifting the debt limit doesn’t authorize new spending. Instead, it allows the government to pay for programs that Congress has already authorized. If the cap isn’t lifted and the government can’t meet its obligations, then it will be at risk of default – a scenario that economists say would be catastrophic not just for the U.S., but the global financial system as a whole. Treasury Secretary Scott Bessent has told Congress that without action, the U.S. will run out of money to pay its bills as soon as August, which means the clock is ticking.

Ending breaks for clean energy

One way Republicans plan to pay for the tax cuts in the bill is by dramatically scaling back many of the tax credits for clean energy passed as part of former President Joe Biden’s Inflation Reduction Act. The bill ends the $7,500 credit for buying an electric car, and also phases out credits for producing or investing in renewable energy sources such as solar and wind.

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Beefing up border security

Changes to border enforcement and immigration policy are a key part of the spending bill. It allocates $46.5 billion toward completing Trump’s border wall. It also allots $5 billion for Customs and Border Protection facilities and more than $6 billion to hire and retain more agents and officers. The legislation also invests in upgraded technology for screenings and surveillance of U.S. borders.

New immigration fees

For the first time in U.S. history, the legislation puts a price tag on applying for asylum, proposing a fee of $1,000. It’s one of a handful of new or increased fees for immigration services. The bill would also create a $550 charge for work authorization applications with renewal every six months. It additionally assigns a $3,500 fee for sponsoring unaccompanied children without legal status, a $1,000 charge for undocumented individuals paroled into the U.S. and a $500 fee for those applying for temporary protected status.

A student loan overhaul

The Republican plan would cut $330 billion from the student loan system by scrapping several existing repayment options, including the Biden-era SAVE program that based payments on income and household size. It replaces them with a new, standard repayment plan and an income-based plan Republicans call their “Repayment Assistance Plan.”

The bill also includes changes to the Pell Grant program for low-income students. Republicans want to increase the definition of full-time college attendance, which is required for students to receive the maximum Pell amount, to 30 credit hours per year. They also plan to require that Pell students be enrolled at least half-time, or 15 credit hours per year, to qualify. An analysis by the National College Attainment Network found that the changes could ultimately result in less aid for many students.

A nurse gives a patient a checkup at an Oakland, California, clinic in 2017. (Carlos Avila Gonzalez/The San Francisco Chronicle via Getty Images)

Medicaid, the joint federal-state health insurance program that covers about one-in-five Americans, may be in for some of the biggest changes in its 60-year history.

The tax, spending and policy bill making its way through Congress seeks to cut hundreds of billions of dollars from Medicaid over the next decade to help offset the measure’s even larger tax cuts. The Congressional Budget Office estimates that the Medicaid cuts, along with changes to other federal insurance programs, would lead to millions of people losing health coverage should the bill become law.

Given the changes that may be in store for the program and its overall complexity, here are answers to some common questions about Medicaid.

What is Medicaid?

Medicaid provides health insurance to various categories of low-income people. It’s funded jointly – though not equally – by the federal government and the states. However, the way the program is structured and run means that in many ways there’s no single Medicaid program. Rather, there are 56: one for each state, the District of Columbia and the five permanently inhabited U.S. territories.

Medicaid was created in 1965 at the same time as Medicare, the federal health insurance program primarily for people ages 65 and older. Both programs are overseen by the Centers for Medicare & Medicaid Services (CMS), an agency within the U.S. Department of Health and Human Services.

The Children’s Health Insurance Program (CHIP), created in 1997, is designed to cover children from families whose incomes are modest but too high to qualify for Medicaid. While CHIP is formally separate from Medicaid, the two programs are closely coordinated in practice. In fact, some states administer CHIP as an extension of their Medicaid programs, while others either operate CHIP separately or combine the two approaches. This analysis will present data for Medicaid and CHIP separately when possible.

Medicaid is broadly popular. More than eight-in-ten U.S. adults (83%) have a favorable opinion of the program, according to a recent survey by KFF, a nonpartisan research organization focused on health policy. That view is shared by 93% of Democrats, 74% of Republicans and 83% of independents.

Is Medicaid eligibility determined by the federal government or the states?

Both. The federal government sets general rules about who always qualifies for Medicaid and which health care services must be covered. Beyond that, states have considerable flexibility to determine the scope of their programs by extending eligibility to additional groups of people (or not) and covering various optional health care services (or not).

For example, under the federal Affordable Care Act of 2010, states can expand eligibility to adults with household incomes up to 138% of the federal poverty level – which in 2025 would be $44,367 for a family of four – with the federal government picking up 90% of the additional cost. Forty states and D.C. have expanded their Medicaid programs in this way, while the other 10 states have not.

Who’s eligible for Medicaid?

Originally, Medicaid was aimed at certain categories of low-income people: families with children, pregnant women, and the elderly, blind or disabled. People in those groups who received some form of public assistance generally also qualified for Medicaid coverage.

Those eligibility groups have broadened over time. States are required to cover some groups – for instance, children in foster care and former foster care youth up to age 26. Coverage is optional for others – for example, pregnant women and infants in households with incomes between 133% and 185% of the federal poverty level. Since each state sets its own eligibility criteria (within broad federal minimums), there’s no simple way to summarize them.

In fiscal year 2022, 36% of all Medicaid enrollees were children, according to the Medicaid and CHIP Payment and Access Commission. Another 26% were adults who had become eligible under the 2010 Affordable Care Act; 18% were adults who’d already been eligible; and 20% were elderly, blind or disabled.

How many people have Medicaid coverage?

As of January 2025, 71.4 million people were enrolled in Medicaid, according to preliminary CMS data. An additional 7.3 million were enrolled in CHIP. Together, the two programs covered nearly 41.4 million adults and 37.4 million children, or 23% of the U.S. population.

Children are covered by Medicaid at a higher rate than adults. We estimate that 41% of all U.S. children were enrolled in Medicaid and 10% were enrolled in CHIP as of January. The two programs combined provided health coverage to more than half of the country’s 73.1 million children. By comparison, Medicaid enrolled 15% of the U.S. adult population as of January.

How has Medicaid enrollment changed over time?

While the long-term trend has been upward, Medicaid enrollment has remained relatively steady for the past several years at around 20% of the U.S. population.

Medicaid enrollment counts are affected by factors including population growth and general economic conditions, since more people become eligible in downturns as they lose jobs and income. But policy changes play a significant role as well: Congress and individual states can expand or restrict eligibility rules and, separately, make it easier or harder for people to enroll and maintain their eligibility status.

During the COVID-19 pandemic, for example, Congress gave states extra money for their Medicaid programs on the condition that they maintain coverage for nearly everyone who was already enrolled in the program (rather than periodically rechecking their eligibility, as is normally required). This “continuous coverage” rule led to a steep rise in enrollment, from 64.8 million in March 2020 to a peak of 87.4 million in April 2023 – an increase of 34.8%.

The extra funds began to phase out in April 2023 and ended completely, along with the continuous coverage requirement, that December. Medicaid enrollment has fallen steadily since then, to 21% of the U.S. population as of January 2025.

How do Medicaid enrollment rates vary around the country?

In January 2025, by our calculations, Medicaid enrollment ranged from a high of 34.2% of the population in D.C. to a low of 8.6% in Utah. Enrollment in CHIP ranged from 4.4% in Oregon to 0.1% in Minnesota. Again, state enrollment rates in these programs depend on factors including local economic conditions and each state’s eligibility rules.

Detailed table: Medicaid enrollment by state in January 2025

What are the demographics of Medicaid enrollees?

Here’s some of what we know, based on 2023 data from the Current Population Survey’s Annual Social and Economic Supplement, or ASEC. (Note that ASEC defines Medicaid to include CHIP and a handful of other state-administered programs for low-income people.)

Women account for just over half of Medicaid enrollees (52.2%), slightly higher than their share of the overall U.S. population (50.7%).

Non-Hispanic White enrollees account for 39.6% of all Medicaid recipients (versus 58.0% of the U.S. population as a whole). Hispanic people, who can be of any race, comprise 30.8% of enrollees (versus 19.7% of the population), and Black people make up 20.8% of enrollees (versus 13.5% of the population). The share of Asian American enrollees (6.0%) was about the same as their share of the overall population (6.6%).

Medicaid enrollees ages 19 to 64 are more likely than Americans in that age group overall to have never been married (47.9% vs. 36.3%) or to be divorced or separated (14.8% vs. 11.1%). They’re much less likely than Americans overall to be currently married (34.9% vs. 51.0%).

Nearly half of enrollees (48.6%) have household incomes of less than $50,000, compared with 23.8% of the general population.

More than half (57.2%) of enrollees ages 26 to 64 have a high school diploma or less, compared with 34.9% of the population in that age group.

17.0% of enrollees rate their health status as “fair” or “poor,” compared with 11.2% of all people surveyed.

84.2% of Medicaid enrollees were born in the United States, 6.6% are naturalized citizens and 9.2% are foreign-born noncitizens. Those shares are all similar to the U.S. population as a whole. Only some noncitizens are eligible for Medicaid; unauthorized immigrants are not eligible for the program.

Are Medicaid enrollees required to work?

In most cases, no. But under the budget legislation pending in Congress, people who qualify for Medicaid under the 2010 Affordable Care Act expansion would have to work, do community service or go to school to retain their eligibility. (Georgia operates a pilot work requirement under a waiver approved during the first Trump administration.)

In a recent Pew Research Center survey, 49% of U.S. adults said they would favor work requirements for most adults who get health insurance through Medicaid, while 32% would oppose such requirements and 18% weren’t sure.

Most working-age adult enrollees in Medicaid already work, according to a May 2025 analysis by KFF.

Just over 31.2 million people ages 19 to 64 were enrolled in Medicaid in 2023, KFF found. More than 2.4 million of them were also covered by Medicare, and 2.7 million received disability benefits from Social Security or Supplemental Security Income benefits. Excluding those two groups of people, who presumptively have disabilities that would exempt them from the work requirements, leaves 26.1 million enrollees. Among that group, 11.5 million worked full time (44.1%) and 5.1 million worked part time (19.5%).

Of the 9.5 million people who didn’t work, 3.2 million cited caregiving responsibilities as a reason, while 1.7 million said they were in school and 2.6 million cited illness or disability.

How much does Medicaid cost?

In fiscal 2023, the most recent year for which detailed financial information is available, Medicaid’s net cost was $894.2 billion. The federal government paid just over two-thirds of that figure ($614.0 billion, or 68.7%), while states, D.C. and territories paid the rest ($280.2 billion, or 31.3%).

Under Medicaid, states pay health care providers up front. The federal government then reimburses states for part of those costs. Those federal payments are a lot larger in some states than others. In fiscal 2023, for example, the federal government paid for 82.1% of New Mexico’s program, 71.0% of Tennessee’s and 59.7% of Wyoming’s. The federal shares of the territories’ programs were all 85% or higher.

The federal matching rates vary because they’re based largely on each state’s per-capita income and are recalculated each year based on new data. In addition, certain services and subgroups of enrollees are reimbursed at their own specific rates.

Historically, the federal government’s overall share of Medicaid costs has hovered between 56% and 59%, though Congress has often raised matching rates temporarily during economic downturns.

The federal share rose above 60% and stayed there after the Affordable Care Act expanded Medicaid eligibility. During the COVID-19 pandemic, when Congress authorized extra payments to states for retaining people on the rolls, the federal share reached as high as 71% (in fiscal 2022).

How much of federal and state budgets go to Medicaid?

In fiscal 2024, Medicaid represented about 8% of all federal spending, according to archived data from the Office of Management and Budget. This was down from a peak of 10% the year before. Medicaid’s share of federal spending grew steadily from the program’s inception until the 2004 fiscal year, and since then it has bounced around more erratically.

State spending on Medicaid varies considerably. Because much of what states spend on Medicaid is ultimately reimbursed by the federal government, a better way to analyze the program’s budget impact is to look only at “locally raised dollars” spent on Medicaid as a share of all locally raised money spent. (We’re using “locally raised dollars” to mean money raised by state and local taxes, fees and assessments, or borrowed by states, whether held in their general funds or other specialized funds.)

Considered that way, Missouri spent the most in fiscal 2023. It spent 25.5% of its locally raised dollars on Medicaid, according to data from the National Association of State Budget Officers. Hawaii spent the least of any state at 5.7% of its locally raised dollars.

Where does all that money go?

In fiscal 2023, a total of $884.4 billion was spent on medical services through Medicaid, according to our analysis of CMS financial data. (That figure includes rebates and offsets of various kinds but excludes $24.5 billion collected from patients and third parties. Net spending on services was $859.9 billion.)

More than half of that money ($460.6 billion, or 52.1%) went to managed-care organizations, or MCOs. Most Medicaid beneficiaries – 85% in 2022 – are enrolled in some type of managed-care plan. Under such plans, states contract with MCOs and pay a fixed monthly fee per enrollee. The MCO then either provides health care services to beneficiaries itself or pays providers to do so.

Almost $112.8 billion (or 12.8%) was spent on home- and community-based long-term care services, while another $60.4 billion (or 6.8%) went for institutional long-term care. All told, 19.6% of all Medicaid spending went to long-term care.

Another $87.9 billion, or nearly 10%, went to hospitals, and $18.8 billion (2.1%) went toward prescription drugs. About $27.6 billion (3.1%) went to pay Medicare premiums and copays for low-income elderly people who receive both Medicaid and Medicare benefits.

In addition, $34.4 billion went to federal and state administrative expenses, amounting to 3.8% of net spending.

How big a role does Medicaid play in U.S. health care overall?

In 2023, Medicaid accounted for 17.9 cents of every dollar spent on health care in the United States, according to health expenditure data from CMS. Excluding medical research and spending on buildings and medical equipment – which Medicaid doesn’t pay for at all – the program paid 18.8 cents of every dollar spent on health care services. Since about 1990, Medicaid’s share of overall health spending has mostly grown, albeit in fits and starts.

Medicaid is a much more significant player in particular areas. For example, in 2023, more than a third of home health care spending and nearly a third of spending on nursing homes came via Medicaid, according to CMS. That same year, Medicaid paid for 41% of births in the country, according to data from the Centers for Disease Control and Prevention.

× Expand Tom Williams/CQ Roll Call via AP Images Demonstrators calling for preservation of Medicaid funding are removed from the House Energy and Commerce Committee markup of the FY2025 budget resolution, May 13, 2025, on Capitol Hill.

Under the guise of strengthening Medicaid, Republicans on the House Energy and Commerce Committee ended a 26-hour markup session last week with a party-line vote to gut the program. The sweeping cuts, which would slash federal funding for Medicaid by at least $625 billion over the next decade, comprise a significant portion of the reconciliation package Republicans are trying to pass before the upcoming Memorial Day recess.

The bill is designed to strip away much of the system of health care provision for the poor and working class in this country. The provisions weave a web of red tape around Medicaid, creating hurdles to access and making it harder to navigate. Republicans would force recipients whose incomes sit at or above the federal poverty line to pay higher out-of-pocket expenses for coverage, repeal Biden-era eligibility and enrollment rules, shift more of the bureaucratic responsibility for determining eligibility to states, and impose work requirements on childless adult enrollees.

The Republican plan also takes aim at a tax loophole states have used to secure additional Medicaid funding from the federal government, seeks to penalize states for using their own funds to cover undocumented immigrants by reducing Medicaid expansion rates, and rolls back the Biden administration’s “safe staffing” rule for nursing home employees.

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The purpose of all this, of course, is to free up budgetary headroom for tax cuts for the rich. Unlike the original Trump tax cuts, which overwhelmingly benefited the wealthy but gave almost everyone at least a little something, this time they would take from the poor to give to the rich. As economist Paul Krugman points out, the bottom fifth of Americans would see their after-tax income decline by about 11 percent, while the top one-thousandth would see theirs rise by about 3 percent.

Rep. Frank Pallone Jr. (D-NJ), ranking member of the committee, has been one of the most prominent dissenting voices on the Democratic side. He bitterly condemned his Republican colleagues for prioritizing billionaires and corporate interests over vulnerable Americans who rely on Medicaid for health insurance. “This is not trimming fat from around the edges, it’s cutting to the bone. The overwhelming majority of the savings in this bill will come from taking health care away from millions of Americans,” he said.

Medicaid is the largest health insurance program in the country. More than 71 million people are enrolled in the program. According to estimates from the Congressional Budget Office (CBO), the cuts would kick 10.3 million Americans off Medicaid, 1.4 million off state-funded programs, and ultimately leave 7.6 million without insurance altogether. Sources previously told the Prospect such cuts do not seem to reach the $880 billion over ten years required in the committee’s budget reconciliation instructions. As millions of Americans’ access to health care hangs in the balance, Rep. Brett Guthrie (R-KY), chair of the committee, will need to get hard-line Republicans calling for deeper cuts to the program on board, as well as moderates who oppose the current scale of such cuts.

Democrats have been sounding the alarm on Medicaid cuts for the past year. During last week’s markup, they fought long and hard against the justifications for slashing the program. House Republicans defended the sweeping cuts, often hurling accusations at Democrats for fear-mongering and supposedly distorting the bill’s true intentions. In the end, Republicans on the committee rejected every Democratic amendment, including one that would have required the Department of Health and Human Services (HHS) to certify that the health care portions of the reconciliation package would not come at the expense of Medicaid benefits offered by states.

“House Republicans seek to obscure the impact of their health care cuts through complicated proposals, like limiting the ways states can fund Medicaid and adding lots of red tape and paperwork that makes it harder for people to get and keep health coverage,” said Sharon Parrott, president of the Center on Budget and Policy Priorities (CBPP). “But here, too, there’s no hiding the outcome: Millions of people, including children, will lose coverage and access to care for life-threatening and chronic illnesses as well as preventive care.”

ALTHOUGH REPUBLICANS INSIST their health care reforms are designed to root out “waste, fraud, and abuse,” imposing work requirements and increasing the frequency of eligibility verification would not strengthen or preserve the program for those who need it most. Such changes amount to onerous paperwork requirements, which appear to be designed to bureaucratically boot people off Medicaid.

For instance, the Republican plan would mandate states to require childless adults to prove that they work, volunteer, or are enrolled in an educational program for at least 80 hours per month on a monthly basis; it would also potentially deny coverage to newly unemployed individuals who are fired or laid off. Caregivers of dependent children, pregnant or postpartum individuals, and people with certain disabilities would be exempt from work requirements, but such people could still lose their coverage through bureaucratic snafus.

All Medicaid enrollees would be forced to navigate complex work-reporting and verification systems every month to retain coverage.

When Arkansas implemented work-reporting requirements for Medicaid recipients during the first Trump administration, the state did not automatically exempt vulnerable groups from work requirements, leading approximately 18,000 people to lose their coverage in the seven months the temporary policy was in effect. The vast majority of enrollees who lost coverage “should have been eligible to retain coverage but did not reapply,” according to CBPP, and a separate report published in The New England Journal of Medicine determined that “nearly everyone who was targeted by the policy already met the requirements.”

All Medicaid enrollees, including the 61 percent of U.S. adults enrolled in the program who already work, would be forced to navigate complex work-reporting and verification systems every month to retain coverage. A recent analysis from CBPP observed that states could opt to implement the mandate more stringently. Furthermore, applicants would be required to comply with work requirements for at least one month before enrolling in the program, and states would have the discretion to require prospective enrollees to be in compliance for “any number of months or even years before they’re allowed to enroll.”

Similarly, increasing the frequency of eligibility verification would also make it more difficult to access the program by halving the Medicaid redetermination period to once every six months and shortening the retroactive eligibility window to 30 days from the current 90-day period. Taken together, these measures would raise the bar for retaining coverage and, in the case of retroactive eligibility, giving states less time to provide coverage for people in complex eligibility situations.

THE CUTS DON’T STOP with Kafkaesque paperwork rules. Republicans would also impose cost-sharing requirements on Medicaid beneficiaries at or above the federal poverty level, and codify the Trump administration’s proposed reductions of Affordable Care Act (ACA) marketplace subsidies.

Medicaid recipients with incomes at or above the federal poverty line, which is $15,650 for individuals and $21,150 for two-person households, would be forced to pay more out of pocket for coverage though premiums, co-pays, and other fees, effectively saddling them with a greater portion of the program’s expenses. Medicaid currently allows states to impose out-of-pocket spending, but some premiums and enrollment fees are limited to beneficiaries above 150 percent of the federal poverty line. Republicans would reduce this threshold to 100 percent.

Another way states have boosted Medicaid funding, as my colleague David Dayen writes, is through the “provider tax loophole,” where states tax their hospitals and spend the money on Medicaid payments to hospitals, triggering additional federal assistance. Republicans would mostly close that loophole too by capping it at 5 percent, even though red states exploit it most aggressively.

Now, capping fees for certain services at $35 per visit and limiting cost-sharing to 5 percent of the income of an individual or household enrolled in Medicaid are perhaps the only commonsense provisions of the bill. But even this small benefit is more than canceled out by yet more proposed cuts to the ACA.

In March, President Trump proposed a rule reducing enhanced premium tax credits on ACA marketplaces, which would make coverage worse and more expensive. That rule might get tied up in court, but congressional Republicans want to codify it into law, rendering legal challenges moot. According to a CBPP analysis, people with chronic conditions will be hit especially hard if the rule goes into effect, as it would raise health care costs “by hundreds of dollars for most of the 20 million people who get coverage through the ACA marketplace.” The House Ways and Means Committee, which focuses on tax policy, will not be extending the tax credits. CBO estimates that 4.2 million Americans will go uninsured as a direct result of those credits expiring, while another 1.8 million will experience coverage losses if the ACA marketplace rule is codified.

“These cuts, even if not specifically directed at community-based disability services, will squeeze a system already in crisis, harming people with disabilities and the workers supporting them,” said Barbara Merrill, chief executive officer at ANCOR. “Despite the insistence by many members of Congress that they don’t want to cut benefits for people with disabilities, drastic funding cuts of any kind will reverberate across states, thereby endangering community-based disability services—the kinds of services that are often first to go when states experience funding shortfalls.”

The fear and anger stemming from the health care portion of the bill reached a boiling point last week. Following a series of demonstrations both within and outside the House Committee on Energy and Commerce markup, the Capitol Police arrested 26 protesters, removing several individuals in wheelchairs from the chamber. Among them was an attendee who rebuked Rep. Gary Palmer (R-AL) for suggesting people with disabilities would not be impacted by the cuts.

“You will kill me,” they proclaimed. “I’m HIV-positive.”

GUTTING MEDICAID will have devastating knock-on effects around the country. That was the conclusion of a report released by the Economic Policy Institute (EPI) earlier this year. “These cuts will not just cause harm to individual families, they will cascade, leading to hospital closures in rural counties, higher medical debt, lower earnings from future workers who will suffer from poorer health decades from now, and could even put upward pressure on federal budget deficits in the long run. In the very near term, these cuts will make the [U.S.] economy far more vulnerable to any recessionary shock.”

Health care providers in poorer regions will feel an especially definitive impact. According to estimates from the Milken Institute School of Public Health at George Washington University, projected declines in revenue across the health care industry could lead providers to shed close to half a million jobs. Hospitals, particularly those operating in rural areas, could be driven out of business by lower revenues and elevated uncompensated care costs.

“The magnitude of the proposals contained in the Energy and Commerce reconciliation text represents a devastating blow to the health and well-being of our nation’s most vulnerable citizens and communities,” said Rick Pollack, president and chief executive officer at the American Hospital Association (AHA).

Declines in revenue across the health care industry could lead providers to shed close to half a million jobs.

Nursing homes would face similar challenges, largely due to a rollback of the Biden administration’s minimum-staffing mandate for nursing home employees. The Biden-era rules require at least 3.48 hours of nursing care per resident per day and a registered nurse on-site at all times. Congressional Republicans are eyeing a ten-year delay of the mandate, arguing that a “one size fits all” approach would lead nursing homes facing staffing shortages to close. The problem with this is that facilities with inadequate staff-to-resident ratios will not be able to provide quality care, jeopardizing resident safety and well-being.

Other health care providers would suffer as well, including Planned Parenthood. The Republican plan would prohibit reproductive health organizations from accessing Medicaid funding; one-third of Planned Parenthood’s revenue comes from the federal government.

“Lawmakers are making it plain: This provision is about punishing Planned Parenthood health centers for providing abortion care, and threatening access to affordable birth control, wellness checkups, and cancer screenings for millions of people across the country in the process,” said Alexis McGill Johnson, president and chief executive officer at Planned Parenthood. “It is indefensible how far abortion opponents, who claim to care about women and families, are willing to go to shut down health centers and line the pockets of billionaires and big corporations.

On top of all this, the health care portion of the GOP mega-bill deliberately targets vulnerable communities by restricting access to gender-affirming care and denying Medicaid to individuals who, politically speaking, are not of “satisfactory immigration status.” Congressional Republicans are prepared to punish states for using state-owned funds to provide coverage for undocumented immigrants by slashing the federal matching rate for the ACA’s Medicaid expansion to 80 percent from 90 percent. Once again, the financial burden would fall on the states, making it harder for emergency service providers to receive payments from undocumented patients, and siphoning money out of the Medicaid expansion group (whose participants are largely U.S. citizens). CBPP denounced the policy, describing it as an attempt to “coerce states into not spending state funds in particular ways.”

THE GOAL OF THE REPUBLICAN PLAN is supposedly to “strengthen Medicaid for those who need it most,” Rep. Guthrie said in his opening remarks during the House Energy and Commerce Committee markup last week. He and his GOP colleagues claimed that they were merely rooting out waste, fraud, and abuse, and accused Democrats of fear-mongering about their plan. The reality, as we have seen, couldn’t be more obvious. The point is to take resources from the poor and working class, in the form of health care spending, and redirect them to the rich.

Since Trump won the 2016 Republican primary promising never to touch Social Security, Medicare, or Medicaid, many speculated that the traditional Reaganite ideology of deregulation and tax and welfare cuts was dead in the GOP. Maybe he would even raise taxes on the rich. But now we are seeing Trump’s Republicans far outdo Reagan at his own game, despite the fact that conservative regions tend to have more Medicaid enrollees than liberal ones. FDR’s New Deal administrative state is being obliterated, and a core part of LBJ’s Great Society is being devastated. “More for themselves, and less for everybody else” is the only Republican tax policy idea in Washington.