Republicans’ Long Held Dream of Slashing Health Insurance for Millions About to Come True

Unfortunately, the decades long Republican party effort to strip millions of Americans from a basic right to health insurance seems  about to come to fruition.

Republican Senate Leader John Thune of South Dakota set this week for the United States Senate to begin passage of its version of the Big Beautiful (awful) Bill, with their July 4^th passage goal for both Houses.

The provisions of their bill would result in 16 million people in the United States  losing health insurance by 2034, according to a letter from the Congressional Budget Office to House leaders .  (I wrote about the devastating impacts of this bill on New York’s budget in my last blog post.)

The health insurance losses stem primarily from a work requirements mandate for childless adult Medicaid recipients, and for allowing significant subsides for affordable care act enrollees to expire.

House Speaker Mike Johnson from Louisiana tried to justify work requirements for many Medicaid recipients by explaining that he believes the government can “return people to the dignity of work instead of playing video games all day.” Of course, this flies in the face of actual facts: the vast majority of adult Medicaid recipients do, in fact, work.

I’ll return later in this article to the Speaker’s indifference to the people of Louisiana and, in particular, his own constituents, but first here is a brief history of past Republican efforts to kill the Medicaid entitlement.

How Did We Get Here?  Republicans Have Been Trying to Cut Medicaid for Decades

The Nineties

During the welfare reform debate of the1990s, the Republicans, controlling both the House and Senate, passed two welfare reform bills that included an end to the Medicaid entitlement, both of which were vetoed by President Clinton . Welfare reform included work requirements and time limits, but Clinton’s vetoes forced the Republicans to decouple the welfare reform from the abolition of the Medicaid entitlement to health care. Welfare was changed but Clinton protected the right to health care.

2017

With the Republicans in full power in 2017, Congress, with President Trump’s support, attempted to repeal the Affordable Care Act. After the House voted the repeal, the Senate took it up. Republican Senator John McCain, battling brain cancer, returned to the Senate floor to vote “No” on repealing the legislation (along with Murkowski and Collins), causing the bill to be defeated 51-49 in the Senate. Once again, the Republicans just barely missed their opportunity to take away health care from millions.

2023

Republicans tried again in 2023, passing a bill in the House to impose work requirements on Medicaid recipients up to age 55, and to increase the work requirements age limit for Food Stamp recipients from age 49 up to age 55. President Biden successfully blocked imposing the work requirements on Medicaid recipients to protect the health care entitlement, but accepted the change for Food Stamp recipients.

Now

With the Republicans back in full power, the House bill that passed on May 22^nd this year requires adults without dependents in the Medicaid expansion category, ages 19 to 64, about 20 million out of the approximately 80 million people on the Medicaid program, to work or engage in defined work activities at least 80 hours a month. The Senate bill adds a Medicaid work requirement for parents of children over 14. The House bill also adds persons age 55 to 64 to the Food Stamp work requirement, beyond the current law requirement to age 54, meaning work requirements for both Medicaid and Food Stamps for persons age 55 to 64 enrolled in either of those programs.  

If you are poor, or near poor, and are in ill health between the ages of 62 and 64, you better not make a decision  to take your Social Security as early as you can if you need Food Stamps and Medicaid health insurance to survive.

The bill gives exemptions for caregivers and the medically frail, to be categorized and clarified by the Health and Human Services Administration prior to implementation, with an implementation deadline for the states of December 31, 2026. (States can go faster if they like.) There are optional hardship exemptions, such as for persons who recently resided in psychiatric institutions, or who live in counties with unemployment rates of 8% and above, or 1.5X the national unemployment rate.

Why This New Bill Spells Utter Disaster

States are required to verify eligibility twice a year, up from once a year in current law, and the work requirements have “lookback windows,” both for existing recipients and new applicants. At application, the individual must  be in compliance with the work requirement in the month immediately preceding application, and states are permitted to impose longer lookback compliance periods. Individuals currently enrolled at the time of the six-month reviews must have been in compliance for at least one month. (States are permitted longer periods, while the Senate bill limits lookback periods to three months.) Individuals who are denied coverage for noncompliance will still have rights to appeal.

Persons who are denied coverage will also be ineligible for subsidized Affordable Care Act coverage!

States will have to set up extensive administrative systems to determine who is working and whether they are reaching 80 hours a month, who is exempt as a caregiver or has some serious medical condition, and provide notices to persons regarding eligibility, compliance determinations, and the like. People  will need to be enabled to report to the bureaucracy to supply missing information and attempt to correct errors, etc. State computer systems would need to attempt to match payroll data from employers, income data, medical data from providers, and timely notices to recipients and applicants seamlessly for all to go well, a likely impossible task.

Arkansas Tried This Before and Failed Miserably

Two Arkansas Legal Aid lawyers, who represented Medicaid recipients when Arkansas imposed Medicaid work requirements during the Trump administration, described in a New York Times opinion column the State’s failure to identify a man’s employment at a poultry plant. He had chronic pulmonary disorder, but Medicaid health insurance helped him work. He lost his health insurance because of difficulty attempting to navigate the State’s new reporting system. He ended up in some minimum wage jobs and passed away a few years later.

Arkansas cancelled the program.

Millions Will Lose Health Insurance

The Congressional Budget Office letter to House leaders described the House bill’s health insurance impacts as leading to about 5.2 million Americans losing Medicaid due to the work requirements, about 5.1 million Americans losing Affordable Care Act coverage primarily from the expiration of subsidies enacted while Joe Biden was President, and millions of other persons losing coverage due to the elimination of funding for legal immigrants or from the interaction of the combination of other cuts, like compelling copayments, ending automatic reenrollments for Obamacare, and difficulty complying with the complicated eligibility reviews.

Most Medicaid Recipients Do Work; False Narrative About “Lazy” Recipients

While polling on the bill shows it to be unpopular on the basic theme of giving to the rich and taking from the poor, questions on the work requirements conducted by the Kaiser Family Foundation (a progressive not-for-profit strongly supportive of Medicaid) indicated about 60% of the American public, including 47% of Democrats, supported work requirements, in part out of a mistaken belief that a majority of Medicaid enrollees are unemployed. (A recent Quinnipiac Poll showed a closer split.) In fact, 64% of adults aged 19 to 64 are working full-time or part-time. Here’s the Kaiser study of this population:

A High Percentage of House Speaker Mike Johnson’s Own Constituents Will Be Tossed Off Medicaid; He Betrays Them to Be in Lockstep with Trump

As I mentioned at the beginning of the article, Speaker Mike Johnson’s cavalier and insulting remarks about forcing people playing video games off Medicaid to justify work requirements belies some of the realities of life’s difficulties in Louisiana.

Here are some Medicaid facts about that state, where the Kaiser Family Foundation had 69% of Medicaid adults in Louisiana working, and 27% of adults ages 19 to 64 on the Medicaid program. Medicaid covers anywhere from 31% to 47% of the residents of the State’s six Congressional districts. Johnson’s district on the map below is the 4^th Congressional district, on the northwest and western section of the State bordering Arkansas and Texas:

Speaker Johnson is also feigning ignorance of the extent of poverty and limited opportunities in Louisiana. According to the United States Congress Joint Economic Committee report for May 2025, Louisiana is tied for the 46th lowest labor force participation rate of the states in the nation, at 57.9% of the civilian adult population, with an unemployment rate of 4.5%. The comparable rates for the nation in May were 62.4% and 4.2% for unemployment. Louisiana’s 2024 employment-to-population ratio was 55.2%; for the nation, they were 62.6% and 60.1%. About 18.9% of Louisianans lived in poverty in 2023 (compared to 11.1% in the U.S.) and the minimum wage there is still $7.25 an hour.

Here’s a look at some of the basic demographic information just in Speaker Johnson’s 4^th Congressional district in Louisiana by parish/county. (LBFPR* stands for labor force participation rate, W/O H.I. stands for without health insurance.)

I took the data from the American Community Survey 2023 Census Quick Facts by parish, and the Employed from the Bureau of Labor Statistics 2024 4^th quarter employment and wages. ** means that the population of that parish includes an adjacent congressional district or districts.

A Congressional district in Louisiana has about 776,000 people, smaller than the population sum of 1.23 million in the table above, so I had to do the best I could to project the data just for the 4^th district. The labor force participation rate and poverty rate were calculated as if there was no distinction between the parts of the parishes in the 4^th Congressional district and the other districts, and there was no variation for persons under 16, the age below which the labor force participation rate is calculated, as the percentage of persons working or looking for work compared to the civilian noninstitutionalized population age 16 and over.

The analysis shows that the labor force participation rate in Speaker Johnson’s district in 2023 was about 54.3%, about eight full percentage points below the national average of 62.6% in 2023. The employment to population ratio is usually about two percentage points below the participation rate at 4% unemployment, meaning the employment to population ratio in Speaker Johnson’s district was about 52%. The rate of poverty in his district is about 19.75%.

Work requirements for Medicaid recipients may be particularly burdensome in a low-wage state like Louisiana, where weekly wages in the seven large parishes were below the national average of $1,507. Average weekly wages in Louisiana ranged from $1,347 in East Baton Rouge to $1,163 in Caddo, the largest parish in Speaker Johnson’s district, according to the Bureau of Labor Statistics 4^th quarter of 2024 Employment and Wages Report for Louisiana. Caddo Parish average weekly wages were 20% below the national average.

An Urban Institute/Robert Wood Johnson study of the Medicaid work requirements, Many Working People Would be Shut Out of Medicaid under Proposed Work Requirements, found the following: “Though 69 % of expansion enrollees without dependents worked or attended school while enrolled in Medicaid, about 1 in 3 who worked or attended school would not have met the work requirements in one or more months because of unstable employment. … The bill’s requirements are structured in such a way that would deny Medicaid to many working people because of the inherent instability of the low-wage labor market, in which jobs are often temporary, seasonal, or part-time; work schedules and hours can fluctuate drastically from week to week in response to changing demand, and jobs have high turnover.”

Discussing the work requirements on NBC’s Meet the Press, the Speaker said, “What Republicans are doing is an important and frankly heroic thing.” In 2024 and 2022, there was no Democratic candidate against him in the majority-win primary system in Louisiana in his district, resulting in no general elections in the Louisiana 4^th Congressional district.

The One Big Bad Bill

As I write, the Senate Republicans are wrangling over the bill’s Medicaid provisions, which directly slash reimbursement to the States and have been rejected by the Senate parliamentarian. Their bill also has deeper tax cuts and higher deficits than the House version. Whether they make their arbitrary July 4^th deadline or not, it will be one big great bill for billionaires and one devastating blow for tens of millions of Americans.