Trump Country Is About to Get Hosed By GOP Lawmakers

Summary

Bulwark Takes: Trump Country Is About to Get Hosed By GOP Lawmakers Release Date: May 7, 2025

Summary

In this episode of Bulwark Takes, host Sam Stein engages in a comprehensive discussion with senior correspondent Jonathan Cohn, delving into the intricate dynamics of the Republican Party's proposed Medicaid cuts and their implications for Trump-supporting constituencies. The conversation unpacks the legislative strategies, potential impacts on various demographics, and the political tensions arising within the GOP as they navigate these significant policy changes.

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1. Introduction to Medicaid Cuts and GOP Strategy

[00:46] Jonathan Cohn:
Jonathan begins by outlining the overarching Republican agenda: implementing significant tax cuts and offsetting the costs through substantial Medicaid reductions. He emphasizes the scale of the proposed cuts, projecting a staggering $800 to $900 billion over the next decade.

[01:36] Sam Stein:
Sam underscores the magnitude by reiterating, "Billion B with a B," highlighting the financial scale of the GOP's plans.

2. The Impact on Republican Base and Medicaid Beneficiaries

[02:10] Sam Stein:
Sam brings attention to the political conundrum Republicans face: targeting Medicaid, a program now expanded and utilized by many rural white Trump voters, a key component of the GOP's coalition.

[02:33] Jonathan Cohn:
Jonathan provides concrete examples of Medicaid's critical roles, such as substance abuse treatment in opioid-stricken regions like Appalachia and maternity care in the South. He explains that cutting Medicaid doesn't just reduce healthcare access but also jeopardizes jobs and hospital operations in these areas.

3. Detailed Examination of Proposed Medicaid Reforms

[03:42] Sam Stein:
Sam introduces Dave Dayan's report on current Medicaid reform proposals, seeking a breakdown of the specific changes under consideration.

[04:31] Jonathan Cohn:
Jonathan details key proposals, including:

• More Frequent Eligibility Checks: Requiring beneficiaries to re-establish eligibility every few months, which could lead to increased paperwork and unintended loss of coverage.

  [04:42] Sam Stein:
  "People don't do the paperwork in time. They lose it, they file it improperly and then yeah, you'll catch some people who may not be eligible. More likely than not, you'll see reduction in forces through attrition."

• Introduction of Cost-Sharing or Premiums: Imposing premiums on Medicaid recipients above the poverty line, effectively reducing coverage for low-income individuals who cannot afford additional costs.

• Work Requirements: Mandating proof of job search or employment, with exceptions typically for students, disabled individuals, and caregivers. Jonathan warns that such requirements often result in millions losing coverage due to administrative hurdles.

[06:12] Jonathan Cohn:
He elaborates on the complications of implementing work requirements, noting, "You will get millions of people lose health insurance as a result. Most of them are people who, when you dig into it, actually, they were still qualified for the program."

4. Complexities of Medicaid Funding and Provider Taxes

[07:14] Jonathan Cohn:
Jonathan discusses a convoluted aspect of Medicaid funding involving provider taxes. He references a New York Times story by Margo Sanger Katz and Sarah Cliff, explaining how states manipulate tax structures to increase federal Medicaid funding, likening it to a "legal kickback scheme."

[07:57] Sam Stein:
Sam humorously remarks, "Alaska, get on it. What are you doing?" highlighting that almost all states except Alaska exploit this funding mechanism.

5. Congressional Budget Office (CBO) Analysis on Coverage Losses

[08:32] Sam Stein:
Sam shifts focus to recent CBO findings released in response to Democratic requests, revealing stark projections of millions losing Medicaid coverage due to proposed reforms.

[09:20] Jonathan Cohn:
He summarizes the CBO report:

• Cost Savings: Potential savings of over $400 billion.
• Coverage Losses: Up to 9 million people could lose Medicaid, with nearly 4 million becoming uninsured.

[10:46] Sam Stein:
Sam acknowledges the perennial trade-off in policy-making: "more money, less insured. Like that is the trade-off here."

6. Political Challenges and Legislative Dynamics within the GOP

[11:30] Jonathan Cohn:
Jonathan assesses the Republican leadership's precarious position, caught between:

• Conservative Fiscal Austerity: Aiming to reduce government spending to fund tax cuts.
• Electoral Realities: Representing districts with significant Medicaid-dependent populations who may oppose cuts.

[12:04] Sam Stein:
Sam clarifies the nature of the GOP's proposed tax cuts, explaining, "they want to extend expiring tax cuts. People will not feel it as a tax cut. They'll feel it as an extension of the rates."

[13:58] Jonathan Cohn:
He draws parallels to past legislative struggles, comparing the current Medicaid debate to the Affordable Care Act (ACA) repeal efforts. Jonathan quotes Don Bacon, a moderate Republican from Omaha, who expressed frustration over the GOP's handling of Medicaid cuts:

[13:58] Don Bacon: "Don't worry about the Senate, they'll fix it. And now we're getting ready to take our third vote on this. We feel like we're being pushed up to the edge of the cliff here."

Jonathan suggests that Bacon's sentiments reflect a broader GOP disenchantment, reminiscent of the ACA repeal challenges where initial House support faltered in the Senate, leaving moderate Republicans vulnerable.

[14:23] Sam Stein:
Sam recalls historical legislative strategies, mentioning the BTU tax during Bill Clinton's presidency as a cautionary tale of ambitious House-passed policies being derailed in the Senate, leading to political fallout for House members involved.

[15:27] Jonathan Cohn:
Jonathan emphasizes the importance of inter-chamber trust and collaboration, noting that the failure to maintain strong working relationships between House and Senate leaders hinders effective policy negotiation, as seen with the ACA's passage.

7. Conclusion and Future Outlook

[16:11] Sam Stein:
Sam wraps up by acknowledging the ongoing nature of the Medicaid cuts debate, highlighting Jonathan's dual focus on policy analysis and political maneuvering. He indicates that Bulwark Takes will continue to monitor and report on this pivotal policy issue, ensuring listeners remain informed on its developments.

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Notable Quotes:

• Jonathan Cohn [01:12]:
  "They want to pass a tax cut. They, they're trying to pay for part of the cost by cutting Medicaid."

• Sam Stein [02:10]:
  "These are the Trump voters who are on Medicaid and Republicans are like, wait a second, we just recruited these people into our political coalition and now we're going to rip apart their health care."

• Don Bacon [13:58]:
  "We feel like we're being pushed up to the edge of the cliff here."

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This episode delivers an in-depth exploration of the Republican Party's Medicaid reform proposals, dissecting their potential socioeconomic impacts and the internal political strife they engender. Through insightful analysis and real-world examples, Sam Stein and Jonathan Cohn illuminate the complexities of healthcare policy reform amidst shifting political landscapes.

Transcript

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[Sam Stein]

Hey, guys, it's me, Sam Stein, managing editor at the Bork, and I am joined by our senior Laura Loomer correspondent, Jonathan Cohn, who happens to also write about policy for us. But his latest newsletter, the Breakdown, did cover Laura Loomer, and it was for a real reason. She has weighed into the. The Medicaid debates in a surprising fashion. All right, Cohen, what is the state of play with the Medicaid cuts here and how House Republicans are structuring what is essentially the only real major piece of legislation that they are going to be considering this year?

[Jonathan Cohn]

Yeah, well, the state of play is I'm writing about Laura Loomer, which is not something I signed up to do with.

[Sam Stein]

I thought we hired Will Summer for that, but apparently it's not enough.

[Jonathan Cohn]

I actually had to ask Will Summer. I'm like, can you give me, like, how do I sum up Laura Loomer in a sentence? So I'm really glad you did hire.

[Sam Stein]

Well, one day he's going to pay it back, and you're going to have to describe how to, you know, talk about Medicaid policy to him for a newsletter, but we'll see. All right, what's the state of play on this substantive stuff here?

[Jonathan Cohn]

Right, Right. So the big picture, right, they want to pass a tax cut. They, they're trying to pay for part of the cost by cutting Medicaid. Big argument in the Republican Party. You have the Medicaid cutters, people. You know, historically, this program's too big. We don't look like it. We want to downsize it, shift more responsibility onto the states. We want up to, you know, 800, $900 billion.

[Sam Stein]

Billion with a B.

[Jonathan Cohn]

Billion B with a B. And that's over 10 years. But that's a, you know, as we like to say, money, even in Washington. Yeah. So that's the, that's the sort of push. And, you know, on the flip side, you have moderates, and not just moderates. It's not even so much about ideology, but it's senators and House members in particular, because right now we're in the House who are like, wait a minute, got a lot of people in my district on Medicaid, a lot more than it used to have, because we've expanded it. If those people lose it, that's going to be a problem.

[Sam Stein]

Just to be clear, the expansion, it's also coincided with these interesting political coalition changes that have seen many more rural whites go into Republican camps here. Like, these are the Trump voters who are on Medicaid and Republicans are like, wait a second, we just recruited these people into our political coalition and now we're going to rip apart their health care. It doesn't make much sense.

[Jonathan Cohn]

Yeah, yeah. And I'll just give you sort of two examples of how that plays off in real life. So, I mean, Medicaid is a huge, huge financier of substance abuse treatment. So if you think about, think of a map where the opioid epidemic was most severe. Right. Where are you talking about? Appalachia, West Virginia. And you got a ton of people in West Virginia on Medicaid. It's paying for their opioid treatment. And then, you know, Medicaid has become this huge payer of maternity care. You know, especially in the south, where you just because of the low income there, you have so many people who qualify for it. And so, you know, if you are taking a big chunk out of Medicaid, you're affecting a lot of people who are part of the Republican coalition now. And by the way, not just the people getting health care. Right. It's jobs, it's hospitals.

[Sam Stein]

Hospitals in rural places. Yeah. All right, let's get wonky here. So Dave Dayan, great journalist, obtained a list of proposals that are under consideration for reforming and cutting Medicaid. You've seen other reporting out there in terms of what's on and what's off the table. Give us a rundown of where we stand in terms of the proposals that are in and that are out.

[Jonathan Cohn]

Yeah. Yes. That's Dave. Dan at the American Prospect got what looks like the current list. And, you know, it's in flux. And this is, you know, it's going to be constantly changing the big ticket items that you see. And I'm looking to make sure I got his list right. This just came out. One of the big ones is a sort of more frequent checks of eligibility. That's a big deal. Sort of, you know, rather than having to establish your eligibility every few months, that is sort of adds a lot of paperwork. And we know from experience that if you do that, what ends up happening. These systems are hard to use. People on Medicaid, so many of them are like seasonal jobs. You know, it's hard to get the documentation right. But Sometimes the, you know, the online systems these states run, they're underfunded, they break down and you end up lots of people getting kicked off the program even though they're eligible. So you know, people lose insurance, it's just, it increases the charges.

[Sam Stein]

People don't do the paperwork in time. They lose it, they, they file it improperly and then yeah, you'll catch some people who may not be eligible. More likely than not, you'll see reduction in forces through attrition.

[Jonathan Cohn]

Yep, yep. And look, I mean the people who argue for this, their whole argument is there's people on Medicaid who aren't eligible anymore, we need to cash them. You will root those people out, but at a cost of kicking off tons of people.

[Sam Stein]

All right, so that's one, that's one that's under consideration.

[Jonathan Cohn]

What else we are seeing according to this reporting, sort of introducing sort of cost sharing or premiums for people who are on Medicaid and above the poverty line. So you know, right now one of the things that happened when the Affordable Care act was they expanded Medicaid. Enough said. Even if you were had income slightly above the poverty line, which isn't a lot of money now $40,000 something for a family of, you know, of three, you could still get Medicaid in recognition of the fact that these are people again working in low wage jobs, multiple part time jobs can't even afford, you know, even if their job does offer coverage, they can't afford premiums. So putting them on Medicaid is a way to get them health care. These are very low income people. We know for a fact they really can't afford, you know, to pay premiums or out of pocket costs in the way that people higher income. So again it's another way of sort of cutting health care for low income people in a way that doesn't look maybe you know, you can sort of sell as not a cut or is like a kind of kinder cut.

[Sam Stein]

Okay, a kinder cut. It's a little bit more blunt than the other proposal, but go ahead.

[Jonathan Cohn]

Yeah.

[Sam Stein]

All right.

[Jonathan Cohn]

It does sound like they are going to add work requirements and that is not surprising. This is something that's been talked about from day one.

[Sam Stein]

So just general gist of it, you have to prove that you're looking for work or have tried to obtain work. Like what is the actual requirement here?

[Jonathan Cohn]

So again we haven't seen the details.

[Sam Stein]

But seen these before.

[Jonathan Cohn]

You know, typically you have to demonstrate that you either have a job or they typically will have some Categories like, you know, if you're in school, you have a disability, you can demonstrate you have caregiving response sometimes. But, you know, we don't know what the exceptions are. But more important, this is, this is just like what we were talking about before. We, we've experimented with these before. What always happens is it's hard to report, it's hard to verify. People get caught up in the wash and millions of people lose health insurance as a result. And most of them are people who, when you dig into it, actually, they were still qualified for the program. They just couldn't, you know, they just couldn't verify it. And then there's, there's one other category that seems to be in there, which is about these provider taxes, which is basically about that. You know, it's a complicated.

[Sam Stein]

I was trying. It is. I was actually trying to read up on it before this video and I was like, what you provide, you're taxing the providers in the states to fund the state match to the Medicaid. It's just blew my mind.

[Jonathan Cohn]

So there's a really good story that was in New York Times a couple days ago. People want to look it up by Margo Sanger Katz and Sarah Cliff, two great reporters that sort of detailing this. But basically because the way Medicaid works with the federal government matching what states, you know, providing funds, you know, most of the funds. But there's a formula which is based in part on when the states spend. And states basically, a long time ago figured out, well, we can kind of come up with what sort of is. I would describe almost as a legal kickback scheme where they basically tax, you know, like the hospital. They say, you, hospital, we're going to tax you. But then that's okay because. Because we're going to then spend more money. We're going to get more money down from the federal government and so you sort of won't have to pay more. It's. I'm sort of simplifying for the sake of doing this without charging. Really helpful, you know. And, you know, people look at this and say, okay, states are gaming the system. And that's fair. I think Aaron's a fair description of what's happening. On the other hand, the entire health care system is like sort of these convoluted arrangements that have been built one on top of the other. And in effect, it's a way to get more federal money into the Medicaid system. And so, you know, you can argue it's not the way the system was designed. You can Argue there are lots of states taking advantage of it. On the other hand, pretty much all the states now except Alaska take advantage of it through this scheme.

[Sam Stein]

Alaska, get on it. What are you doing?

[Jonathan Cohn]

We could do a whole show on health care in Alaska.

[Sam Stein]

I'm sure, I'm sure the numbers will be incredible on YouTube on that one. Let's, let's, let's quickly move to the. Because there's another thing that came out here. So that's the general. Just, I want to just say there are some other proposals that I've read about. You know, they want to be sort of blunt in terms of the matching rate of an expansion. They're talking about spending caps on enrollees. We can get to that in a second because there was another big development today, which was the cbo, the Congressional Budget Office responded to a Democratic lawmaker letter asking for assessments on what the losses in coverage would be if you were to implement some of these proposals. And the numbers were pretty stark. I mean, we're talking about in the millions of people who would lose their health care coverage here. What is the sort of top line takeaways that you had from that?

[Jonathan Cohn]

Yeah. So, you know, the Democratic leaders in the House and Senate asked the Congressional Budget Office. They sort of took the biggest items that were under discussion at the time, some of which look like are definitely ending up in the bill, some of which may not. Again, a fluid negotiation. Who knows where this will be in two weeks, two months. What the CBO found was on the one hand, yeah, if you do the make these changes, you can save a lot of money. You can get hundreds of billions of dollars, which again, is what Republicans are trying to do. Oh, but by the way, millions of people are going to lose health insurance.

[Sam Stein]

Right.

[Jonathan Cohn]

And typically what happens is a ton of people end up losing Medicaid coverage. Some of them find their way to other coverage. And typically it ends up that they're getting, you know, sort of subsidized private insurance through the Affordable Care act, healthcare.gov, but a lot of people end up on insurance. So just to give you two examples here. So we were talking before about this change in this provider rate. We were just speaking a minute ago. So CBO says if you make this change again based on the details they were provided, you know, that you can save, you know, looks like more than $400 billion. The federal government can save, you know, up to more than $400 billion that way. But almost 9 million people lose Medicaid coverage and about half of them or a Little less than half. So 4, almost 4 million end up uninsured. So, you know. Yeah, you know, and then that's true for any of these changes.

[Sam Stein]

I mean, we, that's the trade off. That's always more, less money, less insured. Like that is the trade off here. All right, let's, let's step back for a second. How big a bind do you think the people writing this bill, specifically this portion of the bill and leadership on the Republican side is as these things start to come into focus? I ask that because up until now they've been kind of kicking the can down the road. It's like, look, we're going to fill in the details, just pass the budget framework, we're going to kick it back and forth from the Senate and we're going to listen to the moderates and they're ruling these things out. They're not ruling these things out. And eventually you have to deal with hard numbers and legislative language and we're kind of reaching that point now. So how big a bind do you think they're in?

[Jonathan Cohn]

I mean, it's a big bind. They have two very opposed views. I mean, on the one hand, there's the sort of push to cut spending, reduce government, because these are conservatives, they think that's the right thing to do. They want it to offset the cost of their tax cut, which that is the one thing they are going to do a tax cut. Because what Republicans do, it's not a tax cut.

[Sam Stein]

You keep calling a tax cut, but it's an extension of a tax cut. That. Right. Am I missing something? I mean, obviously they're budgeting in a certain way, but they want to extend expiring tax cuts. People will not feel it as a tax cut. They'll feel it as an extension of the rates.

[Jonathan Cohn]

Right. Although they're also talking about, remember, they.

[Sam Stein]

Want to no tax on tips, no tax on Social Security. Fine, if they can get those, if.

[Jonathan Cohn]

They can get all those. And obviously how much they get depends on how much they can offset. So that's all pushing them. You know, that's momentum in the direction of let's make these big spending cuts. But now, you know, we were talking before, I mean, these are real cuts that are going to affect real districts.

[Sam Stein]

Right?

[Jonathan Cohn]

They're going to feel that and they're.

[Sam Stein]

Going to feel and that's and I'm reminded. So this has got me thinking, I'm trying to think of the parallels, but the best parallel in recent memory is ACA repeal. Right. I mean, in the ACA Repeal. We hit a point where suddenly the CBO score started coming in and they were like, oh wait, we're talking like millions of people losing their coverage on the exchanges or through various other. Wait, you're going to really take out some of these. You know, how are you going to mess with pre existing conditions, the protections in that law? And then it got a little dicey. And then they were like, the House, Paul Ryan and the House were like, don't worry, you passed this bill, but we're not going to actually implement this bill. We just need to keep the process going. And so that was. And at some point, and it was with the Senate where they said, no, we're not going to do this. King specifically at some point, McCain was like, no, we're not going to like have a leap of faith that we will just get this all done in a joint committee. So I don't think we're at that point yet. But I just want to read this quote from Don Bacon, who is the, who was congressman from Omaha, maybe one of like a handful of moderates in the Republican caucus. He says this and this is to Wall Street Journal. Here's the tactic they're using. Don't worry about the Senate, they'll fix it. And now we're getting ready to take our third vote on this. We feel like we're being pushed up to the edge of the cliff here. And to me, that's Bacon basically channeling what people felt like in the ACA repeal debate, which is you're asking us to take a leap of faith that things will get sorted out in the end and all will be well. But eventually it's like you just can't sort it out. Reality steps in.

[Jonathan Cohn]

Yeah, look, that trust or lack thereof between the two chambers is a hugely important factor whenever these things come up.

[Sam Stein]

Right.

[Jonathan Cohn]

You know, I think memories of what happened last time you had a bunch of House Republicans who voted for repeal only to have repealed die in the Senate and feel like I got burned. That's one more reason if you're Don Bacon in a vulnerable district or someone wavering, if you think, you know, you're being asked, you're being pushed to take.

[Sam Stein]

Taking this vote and then you know.

[Jonathan Cohn]

You'Re going to get burned. For now, you and I remember. Do you remember btu, do you remember that phrase, you know, from the Clinton. Maybe it's just me.

[Sam Stein]

No, I do not. I do. I was going to. I was thinking of cap and trade from the Obama years when the House had to vote on that. And it never went anywhere in the Senate.

[Jonathan Cohn]

Perfectly good example. The predecessor that. Oh, God, I feel so old. So the Clinton. This is very famous. The first year of Bill Clinton's presidency, they pushed through similar kind of thing. A carbon tax was called a BTU tax. I don't remember what BTU stands. Something unit. And they got. I think it was. Did they get. I think they got it through the House and then the Senate killed it. And they had all these House Democrats who now had to carry around this vote that got. That was like an albatross, and it hurt them in 94. So this trust is always. And, you know, look, they may overcome it, but they have not done that work. And, you know, and I think a lot about. When you think about the aca, actually, I always say one of the reasons they were able to get over the line on the ACA was because throughout the process and years before the process, they built up a really good working relationship between House and Senate leaders.

[Sam Stein]

Well, this gets us to another place, and we. We're going to talk about this at some point. The reason that the ACA did work is precisely because you had committee chairs who were working on this stuff and who knew other committee chairs, and the House and the Senate, even though they had somewhat divergent views on how to do this, ultimately they are able to sort of talk to each other and reconcile it. And when you push out seniority, when you get rid of those people, when you don't actually work through committee, this becomes a little bit, if not a lot harder. So, yeah, all right, we're going to leave it there, but we're going to check back in repeatedly on this saga because this is the biggest policy issue going right now, maybe one of the only big ones going right now. And we're fortunate enough to have cone on top of it and on top of Laura Loomer and her tweets as well.

[Jonathan Cohn]

It's.

[Sam Stein]

It's a double whammy. You're really pulling double duty here. Maybe we can get rid of all summer. We got you. All right.

[Jonathan Cohn]

Thank.

[Sam Stein]

Thank you, buddy. Really appreciate it.