Perspective on Policy Changes: Medicaid, the Most Important Debate is Yet to Come
After 100 days Congress has enacted few laws; enacted laws are what endures. But the budget legislation debated now is the most important debate of the 119th Congress, with huge impacts to Medicaid
April 30, 2025
As the new administration reaches its 100th day in office, there are many reflections on the work completed so far. Although the first 100 days has seemed tumultuous and consequential with long lasting impacts, it is notable that very few laws have actually been enacted and signed into law. The cuts to the federal workforce, and cuts to medical research are having profound impacts, but in addition to these changes legislation is what has lasting impact, and what is hard to reverse, once passed.
Per reports, the Congress has enacted just five pieces of legislation, the lowest number passed in the last 68 years (in the first 100 days). Enacted legislation are laws that endure and changes in policy, and laws must be enforced (e.g. the Civil Rights Act, the Affordable Care Act). Much has been made of the many Executive Orders signed by the President (over 150 of those). But executive orders are not laws; many times these are just stated goals from the executive that may lead to policy change, and some times executive orders can and are reversed once a new executive takes office (for example, many of the recently signed excutive orders simply reversed ones signed by the previous POTUS).
Most health policy analysts are focused on the budget reconciliation process, which is in progress as House and Senate committees struggle to agree on budget and tax legislation. This is by far the most impotant set of policy changes being considered, which will lead to far ranging impacts on the number of uninsured, out of pocket costs facing low income persons, and revenues to rural hospitals and other providers who will be put at risk.
The public and media spent much time getting upset over the passage of the budget resolutions by the House and Senate, with progressive Democrats complaining about the Senate Leader’s support of the budget resolution. But, again, this budget resolution was not widely understood outside of Washington: it was simply an outline of what the GOP planned to do on the budget, similar to an outline someone writes when they are writing a paper. The resolution’s targets are not enforceable and nothing in the resolution led to actual policy change.
The most important set of policy changes that is being contemplated now as the House and Senate seek to pass a large tax cut of over $4 trillion (actually making permanent low tax rates already in place since the first Trump administration); but to pay for these tax cuts the Congress needs to balance the cuts with budget cuts of a similar amount in order to pass the legislation and avoid a filibuster in the Senate, thus passing the legislation with 51 votes in the Senate (maybe with the Vice President casting the tie breaking vote).
What is well understood in Washington is how narrow the margins are that the GOP has: the GOP can only lose three votes in the House and/or Senate otherwise the legislation does not pass (House margin 220-213, Senate 53-47).
Currently the GOP has factions that disagree significantly over the budget legislation, particularly over the huge proposed cuts to Medicaid. Some members are fine with cutting the $880 billion over ten years that the House Energy and Commerce Committee has been asked to find. But other members in the House (and Senate) have stated publicly that they will not favor major changes to Medicaid that would be required to find $880 billion in budget cuts (see figure for options being considered), policy changes such as:
ending the enhanced matching funds for the Medicaid expansion,
lowering the federal matching rate for Medicaid,
The Medicaid cuts are most problematic for GOP members of the House with many people on Medicaid, including those in rural areas, and those who represent states that expanded Medicaid. Notably, some members of the Senate have also expressed reservations about Medicaid cuts.
Other GOP members, of the House in particular, are seeking larger cuts to Medicaid to reduce the budget deficit.
Source: Center on Budget and Policy Priorities.
Reports are that the House Speaker is urging his members to vote on the budget ad tax bill before early May; the Senate Leader does not believe he can pass the legislation until July 4th. Whether passage can happen or not, it is clear that if this legislation passes, it would have major consequences on those covered by Medicaid, in particular. This debate over the huge tax and spending legislation is the most important fight of the 119th Congress, with the most long-lasting impact.