GOP governors mom as Congress prepares to cut Medicaid spending for their states

GOP governors mom as Congress prepares to cut Medicaid spending for their states

The last time a Republican-controlled Congress and President Donald Trump moved on Medicaid spending, a key political force stood in their way in 2017: GOP governors.

Now, more than 10 years after Congress passed historic Medicaid cuts of about $1 trillion through Trump's tax and spending laws, red state governors are saying little publicly about what it's doing for health care — even as they face reductions that punch multitrillion-dollar holes in their states' budgets.

Medicaid, a program run jointly by states and the federal government, covers more than 70 million low-income or disabled people, including nearly half of the nation's children. Republicans say the $900 billion-a-year program was allowed to grow too large under Democrats Barack Obama and Joe Biden by adding unfinished adults who don't deserve federal assistance, and they have long tried to scale it back.

Some of the biggest health cuts in the legislation, which Trump calls "a big beautiful bill," come through new policies that would reduce enrollment by imposing more paperwork requirements on participants, including requiring many to prove they are working. These policies would only impact those who expanded Medicaid to more low-income people under the Affordable Care Act.

Nineteen of those states are led by Republican governors. Their silence on the law's health measures is to provide political cover to GOP lawmakers from their states as they seek to reduce Medicaid coverage for millions of people they won over the last decade.

KFF Health News contacted all 19 governors to comment on the Legislature's Medicaid cuts. Only six responded. Most said they had imposed work requirements on adult Medicaid enrollees.

“Implementing the work requirement for able-bodied adults is a good and necessary reform so that Medicaid is used for temporary assistance rather than permanent eligibility,” said Drew Galang, spokesman for Gov. Patrick Morrisey of West Virginia.

“Governor Rhoden supports workforce participation as an eligibility requirement for Medicaid expansion,” said Josie Harms, a spokesman for South Dakota Gov. Larry Rhoden, adding that congressional lawmakers support the governor’s support.

In a sign of how the political winds have shifted, neither governor said anything about another of the legislation's significant cuts to provider taxes - a tool that all states use to help pay their share of Medicaid and receive additional funding from the federal government. This change is expected to cost billions.

No more bipartisan issue

In contrast to the radio silence of GOP governors, Democratic governors have been campaigning against the megabill for weeks.

Pennsylvania Gov. Josh Shapiro took to the social platform

“They are rushing to kick hundreds of thousands of Pennsylvanians off their health care — and lie about it,” he posted. “The damage this is doing here in Pennsylvania and across America is staggering and will be felt for years to come.”

In New York on July 1, Gov. Kathy Hochul charged that Trump's legislation would devastate hospitals and could lead to more than 34,000 layoffs in her state.

“The collective impact of the GOP reconciliation bill in Washington, D.C., could force hospitals to critically limit needed services like maternity care and psychiatric care, not to mention downsizing and even close operations,” she said in a statement.

In 2017, the chorus was bipartisan as Republican governors in Ohio, Nevada and Massachusetts spoke against cutting Medicaid. Trump's bill to repeal much of the Affordable Care Act and roll back its Medicaid expansion narrowly failed in the Senate.

“It was surprising that red-state governors, particularly those in Medicaid expansion, have not spoken out against Medicaid cuts,” said Larry Levitt, executive vice president of health policy at KFF, a nonprofit health information organization that includes KFF Health News. “Republican governors were a powerful political force in the failed 2017 effort to repeal and replace the ACA, including Medicaid expansion.”

What's changed since 2017, political experts say, is that there are fewer moderate Republican governors, and the GOP state leaders who championed Medicaid expansion a decade ago are no longer in office.

Additionally, seven of the then-RED states that expanded Medicaid did so through ballot initiative, largely because of opposition from their governors.

In fact, the Medicaid work requirement is supported by many Republican governors, even if it means less federal Medicaid money and results in fewer people covered.

Several states, including Arkansas and Ohio, have already passed state laws to implement a requirement that adults enrolled under the ACA's Medicaid expansion volunteer, attend school or participate in job training. Most states have yet to get work requirement programs up and running as they await approval from the federal government.

Charles "Chip" Kahn, president of the Federation of American Hospitals, a trade group of investor-owned hospitals, said fewer governors have publicly tried to block Medicaid cuts under the law, but federal lawmakers are hearing from lawmakers in their states.

A policy dilemma for Republican governors is that, unlike 2017, the bill before Congress is not legislation explicitly aimed at repealing Obamacare. With a broader scope than health care, it would expand many of Trump's tax cuts and direct new spending on border security, immigration enforcement and the military, while reducing spending on health care.

“It’s like playing multi-dimensional chess instead of focusing on one topic,” Kahn said.

Larry Jacobs, director of the Center for Politics and Governance at the University of Minnesota, said some Republican governors may have privately expressed concerns with their states' GOP senators but are not speaking out publicly because they are afraid of drawing Trump's wrath.

"Why are they caged? Trump and not 'Liz Cheney'd,'" Jacobs said, referring to the Republican former Wyoming lawmaker whom Trump helped after becoming the vice chairman of an investigation into his attempts to overturn the results of the 2020 election.

Political coils go

Politically dangerous Republican lawmakers face the public question that Trump remains explicit. On June 29, Sen. Thom Tillis (R-N.C.) announced he would not run for re-election after raising concerns about the law and the president supporting a primary challenger. Tillis was one of three GOP senators to vote against it on July 1, although it still narrowly passed.

In addition to the work requirements, the largest Medicaid cuts in the bill rely on restrictions on provider taxes - levies that states impose on hospitals, nursing homes and other health care facilities to increase their federal reimbursement. Much of the additional money is then given back to health care providers in the form of higher payments for their Medicaid patients.

The practice, which has been adopted in every state except Alaska, has been criticized by some Beltway Republicans as "money laundering" — even though the taxes are approved by state legislatures and the federal Centers for Medicare & Medicaid Services and have been authorized under federal law for decades.

The Senate bill would limit the money states could raise — a move that would mean billions in funding cuts for states and their hospitals.

The states with Republican governors that have expanded Medicaid are Alaska, Arkansas, Idaho, Indiana, Iowa, Louisiana, Missouri, Montana, Nebraska, New Hampshire, Nevada, North Dakota, Ohio, Oklahoma, South Dakota, Vermont, Virginia, West Virginia and Utah.

One of the governors who expressed concerns about repealing Obamacare's Medicaid expansion in 2017 was Jim Justice of West Virginia, a Democrat at the time.

In a June 2017 letter to West Virginia Sen. Shelley Moore Capito, a Republican, Justice wrote: "With so many of our employees counting on Medicaid, any cut to Medicaid would devastate West Virginia families." He added that “the consequences beyond that would be catastrophic.”

On July 1, Justice, who was elected to the Senate as a Republican last year, voted for Trump's megabill, including his Medicaid cuts.

“The senator believes this bill strikes a good balance between protecting the most vulnerable and those who rely on the program, while eliminating waste, fraud and abuse to ensure the program is delivered efficiently for those who deserve it,” said William O’Grady, a spokesperson for Justice, in a July 2 email.

KFF Health News correspondent Arielle Zionts contributed to this report.

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