At 10% of the federal budget, it’s reasonable for Medicaid spending to be under a microscope. The upcoming changes in congress and the White House mean a new set of eyes will be focused on it, and specifically on the Affordable Care Act’s (ACA) Medicaid Expansion, which currently provides funding to states to cover beneficiaries at income levels up to $43,000 a year for a household of four.

While the future is always uncertain, the ACA, otherwise known as Obamacare, has generally proved to be resilient for the past decade. In fact, the law currently has its highest approval rating ever measured, with a majority of Americans across the political spectrum holding a favorable view of Medicaid, and wishing Medicaid Expansion to remain in place.

www.kff.org/interactive/kff-health-tracking-poll-the-publics-views-on-the-aca/#?response=Favorable–Unfavorable&aRange=all

Nevertheless, discussions of spending cuts still include Medicaid. In this context, it’s worth remembering that eight years ago in 2016, Republicans declared their intent to repeal the ACA if they gained the power to do so. They then won control of the White House, and both chambers of congress, yet were unable to walk back Obamacare due to political backlash, internal disagreements, and the lack of a replacement plan. Since then, nine additional states have expanded Medicaid, most of which are Republican majority, making the politics of repeal even more complicated.

None of this means Medicaid will go unscathed. However, critics of Medicaid ultimately find themselves in a bind. On the one hand, they want to shrink government spending and reduce citizen reliance on a public healthcare program. On the other hand, the success of Medicaid in providing coverage to millions of previously uninsured or underinsured Americans is too powerful to ignore. So, they sometimes offer ideas for policy changes such as work requirements and block grant funding, which are theoretically more aligned with conservative principles. Few states have run those experiments, but Georgia offers one example of a work requirement implementation. The intentions behind it align with the ideals of the lawmakers who passed it, but when it comes to results, the devil is in the details:

“To reduce the role of the federal government in health care, the state orchestrated an expensive federally funded government program that spent little on health care. As of March 31, roughly $25 million of the $32.5 million spent on the program had been for administrative costs…those administrative costs meant the state was spending significantly more to insure someone…than it would through traditional Medicaid expansion.”

It’s hard to claim victory when public spending increases only to have fewer people insured by Medicaid than would have otherwise been the case. Keep in mind that Georgia is among the ten states that have not expanded Medicaid. So while their program may be deemed a failed effort, it didn’t actually revoke coverage from people already reliant on it. A similar program in the forty states (plus DC) that have expanded Medicaid would come with much higher risk.

With that said, nine states have trigger laws that would immediately and automatically cancel their Medicaid Expansion if the federal money that funds 90% of it were to dry up. This dynamic may or not sway decisions, but it will at least be a consideration for the incoming administration.

While no one can be sure of what will happen, tinkering with the ACA’s Medicaid Expansion at the federal level can be expected to kick millions of Americans off of their health insurance. Although cutting federal spending was certainly a campaign promise, increasing the number of uninsured Americans may prove to be every bit as politically costly as it has been in the past. Stay tuned.