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Texas leaders have long been opposed to Medicaid, the federal-state health insurance program that serves millions of low-income and vulnerable residents.
They rejected additional federal funds that, under the Affordable Care Act, would have enabled Medicaid to provide health care coverage to more low-income families. The state was one of the last to provide women with full-year insurance coverage after giving birth.
When the federal government ended a policy requiring states to keep people on Medicaid during the coronavirus pandemic last year, Texas officials rushed to kick off those they deemed ineligible, ignoring repeated warnings that the expedited process could result in some people being wrongfully removed.
When Donald Trump takes office for the second time in January, Texas leaders may have another opportunity to whittle down the program, this time with fewer constraints.
Trump has not announced any plans to cut Medicaid, which covers approximately 80 million Americans, and his campaign has not responded to requests for comment.
Health care advocates and experts, on the other hand, believe that his previous efforts to reduce the program, as well as positions taken by conservative groups and Republican lawmakers who support him, indicate that it will most likely be targeted for significant cuts.
“We expect the Republicans to move very quickly to cut Medicaid dramatically and, indeed, end its guarantee of coverage as it exists today,” said Joan Alker, executive director of Georgetown University’s Centre for Children and Families in Washington, DC.
Currently, the federal government pays for nearly 70% of Medicaid spending, with states covering the remainder. (A state’s share varies primarily according to the percentage of impoverished residents.)
Any decisions to reduce federal spending would almost certainly lead states to reduce the number of people they consider eligible as well as the care to which enrollees are entitled, according to Alker and other experts.
That would be especially devastating in Texas, which already has one of the lowest Medicaid coverage rates in the country, and officials lack the political will to make up the funding gap with state funds, according to experts. To be eligible for Medicaid, parents with two children must earn less than $285 per month.
“Our elected officials would have to decide whether they want to cut health care for pregnant women, children, people with disabilities, or seniors, because that is essentially who Medicaid covers in Texas,” Adriana Kohler, policy director for Texans Care for Children, a statewide nonprofit that advocates for families, said in a statement.
Spokespeople for Republican Gov. Greg Abbott and the state’s Health and Human Services Commission did not respond to multiple requests for comment.
Abbott previously served as the state’s attorney general, where he helped lead a successful lawsuit against the federal government, ensuring that states would not lose Medicaid funding if they refused to cover more residents under the Affordable Care Act.
Even when Texas provides Medicaid coverage to its most vulnerable residents, state officials have enabled a system that frequently creates insurmountable barriers to receiving care.
According to a 2018 Dallas Morning News investigation, some of the insurance companies Texas hired to administer Medicaid benefits routinely denied expensive and, in some cases, life-saving treatments in order to increase profits. Critics claim that problems with the system persist despite legislative reforms prompted by the series of stories.
Texas covers more than 4 million residents through Medicaid, which is a smaller percentage of the total population than almost any other state. Despite its vast size, the state still serves the third largest population in the country, trailing only California and New York.
According to KFF, a national health policy research organization, the program serves three out of every eight children in Texas, three out of every five nursing home residents, and two out of every seven people with disabilities.
It is the largest funder of nursing homes and long-term care services for the disabled and elderly, and it covers nearly half of all births in the state.
Michael Morgan, a 75-year-old retired nurse from Fort Worth, is among those concerned that if Trump caps or reduces the amount of money the federal government spends on Medicaid, the state will make it even more difficult to get coverage for his daughter Hannah.
She has Down syndrome and schizencephaly, a brain malformation. She is deaf and partially blind, unable to speak, and requires assistance to walk and eat.
Morgan is depleting his limited savings to cover Hannah’s medical expenses after she lost Medicaid coverage earlier this year when she turned 19. In May, he submitted a new application for her; she should be eligible for Medicaid due to her disability.
In November, state officials denied her coverage, claiming Morgan failed to return a form granting the agency access to his daughter’s medical and financial records by the deadline. Morgan, who plans to appeal the denial, stated in an interview that he received the form one day before the deadline.
“I don’t know how much more they can cut it,” he said about Medicaid in Texas.
During his first term, Trump tried unsuccessfully to repeal the Affordable Care Act, which covers 45 million Americans.
His administration also repeatedly advocated for Medicaid spending caps, including block grants that would provide states with a set amount of federal funding regardless of how many people needed insurance or how much their health care cost. Currently, Medicaid covers all people who qualify, regardless of cost.
While those efforts did not make significant progress during Trump’s first term, Republicans will control both the House and the Senate in January, and they have indicated an openness to imposing spending caps and requiring that the majority of adults in the program work. They argue that Medicaid spending is unsustainable and prone to waste, fraud, and abuse.
Republicans who have supported such measures include U.S. Senator John Cornyn and Lubbock Republican Rep. Jodey Arrington, who chairs the House Budget Committee.
Republican policy primers, including Project 2025, published by the conservative think tank The Heritage Foundation, and one from the Republican Study Committee, a conservative congressional caucus, have also advocated for Medicaid cuts.
Arrington, whose spokespeople declined repeated requests for an interview, told reporters last month that he supported a “responsible and reasonable work requirement.”
Harvard University health professors who studied a previous work mandate in Arkansas, which Trump allowed during his first term, discovered that most adults using Medicaid were already employed or qualified for an exemption, but thousands of residents lost health care, at least in part due to the onerous process of constantly proving their eligibility.
Arrington has previously pushed for work requirements and sought to reduce the federal government’s share of health-care costs paid to states. He previously proposed cutting federal Medicaid spending by more than 25%, or $1.9 trillion.
Cornyn, whose spokespeople have repeatedly declined to comment, stated last month that he will not support cuts to Medicare, the federal health insurance program for seniors and the disabled, or Social Security. Nonetheless, he implied that Medicaid cuts were on the table.
“We can’t just keep doing things the way we’ve been doing them,” Cornyn told Politico Pro. “Block grants make a lot of sense.”
William T. Smith, a 65-year-old retired construction worker who lives near the US-Mexico border in Brownsville, said he voted for Trump in part because he believes “there’s too much fat” and supports cutting some federal programs.
Smith has chronic obstructive pulmonary disease, which damages his lungs and makes it difficult to breathe. He claimed to have bipolar disorder, sleep apnoea, and chronic pain as a result of decades of manual labour.
Smith stated that Medicaid, which he has been attempting to obtain since the summer, should not be one of the federal government’s priority areas for cost savings. Instead, he proposed that the federal government use savings from other programs to fund more people’s care.
“I don’t think they’re going to yank health care away from people,” he told reporters. “If they do, I’d be really angry.”
