ASHINGTON — It’s among his most famous campaign promises: Donald Trump pledged he would not cut Medicaid as president.
But the legislation that Trump has aggressively promoted, and that Congress is expected to vote on Thursday, appears to do exactly that. It would reduce Medicaid spending by hundreds of billions of dollars over 10 years, compared with current law, while dramatically altering the financing of a program that covers 70 million Americans.
The White House, however, says it is not “cutting” Medicaid.
STAT asked the White House for an explanation, and turned to two experts — one on the left, one on the right — to make sense of it all. Here’s what we found.
What Trump said
Trump’s comments don’t leave much room for ambiguity.
“I’m not going to cut Social Security like every other Republican and I’m not going to cut Medicare or Medicaid,” he told the conservative Daily Signal, shortly before officially announcing his candidacy.
He said it again and again — including on Twitter.
I was the first & only potential GOP candidate to state there will be no cuts to Social Security, Medicare & Medicaid. Huckabee copied me.
— Donald J. Trump (@realDonaldTrump) May 7, 2015
Trump continually placed Medicaid alongside Medicare and Social Security — America’s biggest entitlement programs — in a trio of sacrosanct programs.
“Save Medicare, Medicaid, and Social Security without cuts,” Trump said during one rally, in campaign footage pulled by CNN.
What the White House says
But when the Congressional Budget Office issued its initial analysis of the Republican health care bill, its verdict on Medicaid was quite clear: Spending on the program would decrease and millions fewer people would be enrolled over the next decade, compared to current law.
Why? The Affordable Care Act expanded Medicaid to allow more people to enroll. The GOP bill both phases out that expansion and fundamentally restructures the overall program’s financing, capping the federal government’s contributions at a certain amount for each person enrolled.
STAT took that apparent contradiction to the White House last week.
“We are capping the growth rate of the program, not cutting it,” a White House official said, speaking on condition of anonymity to address the matter more candidly. The official argued that the formula being used to calculate federal Medicaid spending increases at a higher rate than the program’s spending has recently grown.
Nonetheless, the bottom line from the CBO, the independent scorekeepers of what legislation would do, was that Medicaid spending would be $880 billion less over 10 years under the bill than if the current system remained in place.
What the experts say
Two outside experts — one critical of the GOP plan, another from a right-leaning think tank — sided with the CBO. This is a cut to Medicaid.
“The CBO analysis makes clear it is a cut,” Joan Alker, who studies Medicaid at Georgetown University’s Center for Children and Families, said in an email.
She noted that, per the CBO’s analysis, Medicaid spending is currently projected to increase at a 4.4 percent rate. The formula used in the original GOP bill increases spending at a 3.7 percent rate, according to the CBO.
Republicans have modified the bill since the CBO analysis and increased the Medicaid formula for some, but not all, enrollees. A new analysis is expected, but it seems certain that the office will still project lower Medicaid spending than current law.
Joe Antos, who studies Medicaid for the right-leaning American Enterprise Institute, said it was pretty plainly a spending cut.
“By slowing Medicaid spending down, putting on the budget hat, it is a cut. They’re projecting some savings,” he told STAT. “It’s hard to deny that.”
There are some open questions about the on-the-ground consequences. The Trump administration is pledging to give states more flexibility to administer their Medicaid programs. But nonetheless, the reality of Medicaid cuts — to both spending and enrollment — seems clear after the CBO analysis.
How does Antos square that with Trump’s campaign promise?
“I personally discount what Trump said before he was elected,” he said. “Nothing against him personally, other than he clearly wasn’t working on health policy.”