As Congress considers cuts to Medicaid, advocates warn that proposals will hike state costs or reduce services for people with no other resources. (Getty Images)

Of the laundry list of proposed Medicaid cuts circulating on Capitol Hill, policy watchers say some stand out as the most likely to be implemented because they’ve either been tried before, frequently embraced, or both.

Advocates argue that none of the ideas will actually help the program do a better job of its central mission: make it possible for poor and low-income people to get either primary or long-term health care. Instead, they contend, the outcome would be to transfer the costs to states unwilling to cut services or kick people off the rolls who have no other health care resources.

Broad outlines of the proposed Medicaid wish list for Congressional Republicans were outlined in a U.S. House memo that Politico published in mid-January, along with 50 pages of details. The memo is the basis for a summary of those proposed cuts from policy analysts and advocates at the Georgetown University Center for Children and Families.

Among the proposals that have garnered the most attention and concern are:

• Instituting work requirements for Medicaid recipients.
• Capping the current federal contribution to a state’s Medicaid budget, also known as turning Medicaid funds into a state block grant.
• Lowering the federal government’s minimum share of the cost of Medicaid, currently 50%.
• Ending the increased federal government match for states that have adopted Medicaid expansion under the Affordable Care Act (ACA)

Additional proposals would make other changes to how the federal matching rate is calculated or applied and reverse several Biden administration rules that made Medicaid enrollment easier and broadened access to benefits, according to the Georgetown summary.

Medicaid is funded by a combination of federal and state money. Proposals that lower the federal share would require states to pick up a larger share of the cost to avoid reducing coverage.

“The scale of the cuts Congress is contemplating is so large it really will cause fiscal peril for the state,” says Tamara Jackson of the Wisconsin Board for People with Developmental Disabilities.

Medicaid work requirements

The congressional proposals include imposing work requirements for “able-bodied” people as a condition of receiving Medicaid.

The congressional memo specifies that work requirements would not include “pregnant women, primary caregivers of dependents, individuals with disabilities or health-related barriers to employment, and full-time students.” It pegs the savings from a work requirement at $100 billion over 10 years.

According to KFF, a nonpartisan, nonprofit health policy research organization, however, more than two-thirds of Medicaid recipients are working, and those who aren’t would largely fall into the groups the memo says would be exempt.

The first Trump administration approved state Medicaid program waivers that included work requirements, while the Biden administration withdrew its approval. Among them was a requirement in Wisconsin dating from the administration of former Gov. Scott Walker.

The GOP majority in the Wisconsin Legislature passed a bill in 2022 that included a Medicaid work-requirement variation, but it was vetoed by Gov. Tony Evers.

According to KFF, a Congressional Budget Office analysis of a 2023 U.S. House proposal to institute Medicaid work requirements found that while it would save the federal government $109 billion, it would also increase the number of uninsured people by 600,000 without increasing employment. An Arkansas work requirement instituted in 2018 but later found unlawful by a federal court led 18,000 people to lose coverage.

“What we know is, even though people are working or would be technically subject to exemptions, there are very significant administrative burdens on enrollees to prove that or be found ineligible,” says Richelle Andrae, associate director of government relations for the Wisconsin Primary Health Care Association. The organization represents federally qualified health centers that serve low-income patients, including those on BadgerCare Plus and those who are uninsured.

“More time-sensitive paperwork and steps that are hard for people to understand or do and lots of people trying to complete administrative tasks at the same time are a recipe for mistakes, by individuals and government agencies that must do the work,” says Jackson. “That is how policies like work requirements and more frequent eligibility checks save money. Eligible people lose coverage or struggle to get in.”

Block grants

Currently Medicaid pays states at least 50% of all Medicaid costs, with states paying the balance.

In President Donald Trump’s first term, his administration attempted to replace that long-standing guarantee with a block grant — a fixed amount of money per Medicaid beneficiary in the state, regardless of the actual cost.

That per-patient cap on federal funds “would instead radically restructure Medicaid financing,” according to the Georgetown summary.

The cost would be felt across the board, from long-term care in nursing homes or in the community home care to primary health care through BadgerCare Plus, health care providers say, to the detriment of patients.

“Whatever the proposals are that are at the federal level — changing the formula, [per-patient] caps, at the end of the day they they’re all aimed at reducing funding for the Medicaid program, and it really is a vital lifeline for long-term care services and support,” says Lisa Davison, executive director of LeadingAge Wisconsin. The organization represents nursing homes and assisted living providers in the nonprofit, publicly owned and for profit sectors.

Reducing support would send some patients who now have Medicaid coverage back into the pool of uninsured people, says Patricia Sarvela, chief development officer for Partnership Community Health Center, a federally qualified health center in the Fox Valley that serves uninsured people as well as BadgerCare recipients.

Lacking health insurance, people are likely to put off addressing symptoms until their condition worsens enough for them to go to the emergency room, Sarvela says.

Directly or indirectly, taxpayers will likely wind up having to cover the cost of that care, however. “There might be short-term federal savings but ultimately at the end of the day it’s going to cost the taxpayers a lot more because patients will then not have health insurance,” Sarvela says.

Changes to federal match

Several proposed changes relate to the amount of the federal Medicaid match or how it’s calculated.

A proposal published by the Paragon Institute in July 2024 calls for reducing the federal match below 50% of the costs. The Paragon Institute has close ties to the Heritage Foundation, which produced Project 2025, the 900-page document that, although disavowed by Trump last year, has been echoed in numerous actions since he took office.

In 10 states the federal match is at the minimum and would likely be lowered, the Georgetown summary says, adding: “These states would likely have to make deep cuts to their Medicaid programs in response.”

The states are California, Colorado, Connecticut, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Washington and Wyoming.

Other states receive a higher federal match; Wisconsin gets 60% of its costs covered. It’s not clear whether those states’ matches would also be reduced under the proposal or other Medicaid reduction proposals.

Medicaid expansion

Another likely cut would be to reduce the additional federal match for Medicaid recipients whose incomes are between 100% and 138% of the federal poverty line.

The additional match was included in the Affordable Care Act, enacted in 2010. Originally Medicaid expansion was mandatory under the act, but a subsequent U.S. Supreme Court ruling that upheld the ACA made Medicaid expansion voluntary.

States that have accepted the expansion got a 90% federal match for the added beneficiaries. The Congressional memo proposes ending the higher match, and some states that have expanded are already considering ending expansion if that happens.

Wisconsin never accepted Medicaid expansion, however, so that change would not directly affect the state. Although Evers first ran in 2018 on a vow to accept Medicaid expansion after Walker rejected it, he’s been blocked from doing so by the GOP majority in the Legislature.

As he has with every budget he’s proposed since taking office, Evers has included accepting Medicaid expansion in his 2025-27 budget proposal.

In an interview with the Wisconsin Examiner last month after a visit with constituents in Port Washington to promote his budget, Evers said he didn’t consider leaving out Medicaid expansion, despite predictions that it would be pulled back by Republicans.

“First of all, we don’t know if it’s going to go away,” Evers said. Under the current 90% match, he said, Wisconsin would get about $2 billion in additional federal money every two years and the additional people covered in the state “would get better health insurance, so it’s a win-win-win.”

Evers acknowledged that in the current Congress, there’s a risk for sharp reductions in Medicaid.

If that happens, “it would be disastrous,” Evers said. “We have lots of people on Medicaid in the state of Wisconsin.”

Among states, Wisconsin’s Medicaid profile is “pretty average,” he added.

“There are places in the country where Medicaid is a huge, huge player, and if they would get rid of Medicaid, our health care system would implode. There’s just no question about that. That’s the thing that concerns me.”

This story is Part Three in a series.

Read Part One: Wisconsin patients, families are wary as Congress prepares for Medicaid surgery

Read Part Two: How Medicaid fuels an economic engine for caregivers, family members and patients

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The national fertility rate — calculated as the total number of live births per 1,000 women of reproductive age — has been declining steadily in the United States over the past decade, from 62.5 in 2013 to 54.5 in 2023, according to the Centers for Disease Control and Prevention.  (Photo by Oscar Wong/Getty Images)

Clare Barkley of Ohio always pictured having a second baby. But watching the erosion of reproductive rights and fights over public education and health care, she said the world feels like it’s in upheaval and isn’t sure she wants to roll the dice.

Kristen Witkowski, a North Carolina mom of two, has had several life-threatening complications related to her pregnancies. She might have considered having a third child but is now so terrified of getting pregnant again, she said she wishes she’d had her fallopian tubes tied during her second Cesarean section.

And Brenna Craven Dumas, a mother of two in Arizona who had high-risk pregnancies, wanted to be so sure she didn’t have another, she got her tubes tied and asked her husband to get a vasectomy.

These women live in states that currently or previously had abortion bans, and cited those policies as part of or the primary reason for their fertility decisions.

The national fertility rate — calculated as the total number of live births per 1,000 women of reproductive age — has declined steadily in the United States over the past decade, from 62.5 in 2013 to 54.5 in 2023, according to the Centers for Disease Control and Prevention. The data shows the decline is present in every state to varying degrees. During the same time frame, rates have fallen steeply in states with abortion bans, including Idaho, where the rate dropped from 71.8 to 57.5, and Arizona, which fell from 66.3 to 54.1.

Those falls in fertility have been top of mind for elected politicians tied to President Donald Trump’s second-term administration. It is a central piece of Project 2025, the blueprint for Trump’s presidency as written by the conservative Heritage Foundation and several anti-abortion organizations.

In a memo issued on Jan. 29 by new U.S. Department of Transportation Secretary Sean Duffy, programs supported or assisted by transportation funds have been directed to give preference to communities with marriage and birth rates higher than the national average. As a congressman for Wisconsin, Duffy supported and co-sponsored many anti-abortion bills, including a bill to defund Planned Parenthood.

Vice President JD Vance has expressed concern over declining fertility rates for several years, and repeatedly drew attention during the 2024 presidential election for negative comments he made about women without children and society as a whole becoming too detached from the ideal of becoming a parent. He has argued that policies limiting or prohibiting abortion access, which he supports, are not contributing to the rates, and advocates for higher taxes for those who don’t have children and for expanding the child tax credit to help families.

“Our society has failed to recognize the obligation that one generation has to another is a core part of living in a society to begin with,” Vance said at the annual anti-abortion March for Life event in January. “So, let me say very simply: I want more babies in the United States of America.”

Why fertility rates are lower

Phillip Cohen, a sociology professor at the University of Maryland who specializes in population science, said birth rates have been declining for centuries as modern culture shifted away from using children as a source of labor.

“So that gets you down from eight children per woman to three or four, and then the question is, what makes you continue to go all the way down to very low numbers?” Cohen said.

In the past two decades, he attributes the decline to positive and negative factors. People have more opportunities to spend their time in other ways, especially women, along with more career and life goals that previously were more difficult or impossible to pursue. Although some women manage both a career and a family, there is often pressure to choose one for financial, societal or individual reasons.

The negative factors that are driving down rates, Cohen said, are the expenses of having children, uncertainty and risk.

“(There is) concern about being able to raise children who are competitive in an increasingly unequal world and who can succeed in a society where the penalty for not succeeding seems to be growing,” Cohen said. “If you’re worried about how your kids are going to turn out, and Americans really are … then you can increase your chances of your children succeeding by having fewer of them.”

That rings true for Katie T. in Alabama. Growing up in Alabama as one of four children, she always thought that she would have a big family — probably five kids.

But with the past few years of political developments, including Trump’s re-election, the economy and five months of being a first-time mom, she has decided one baby is enough.

She and her husband are “one and done” after their son, who was born in August. Throughout her pregnancy, Katie said she was already stressed about living in a state with a near-total abortion ban in case anything went wrong, especially as a pregnant woman close to 35, the age when pregnancies are medically considered higher risk. The closest state with broad abortion access is Virginia, which is about 10 hours away by car.

“After I had my baby, I went in for my first checkup to talk about birth control options, and I talked with my husband at length about how I just don’t think (more kids are) in our future anymore,” said Katie T., who asked not to use her last name out of fear of retaliation in her community for her political beliefs.

Not only that, but finances also weighed heavily.

“We are realizing now that daycare is a literal second mortgage payment, and we just can’t afford that,” she said.

Not having a sibling for her son is a disappointment, she said. Her siblings are all older than her, and she describes growing up essentially as an only child, so it was important to her for a long time to have more than one child. But facing a reality of political fights over vaccines and the education system, along with more potential restrictions to reproductive health care, Katie said she had an eight-year birth control implant placed right after the election.

“I hope he will forgive us one day for that,” she said.

‘If something happens, where do we go from there?’

Kiley DeVor, 28, moved from California to Idaho to obtain a degree in physical therapy, and she specializes now in pelvic floor therapy. She and her husband bought a house, thinking they could stay in Idaho for a while, until the U.S. Supreme Court issued the Dobbs decision in June 2022 and Idaho implemented its near-total abortion ban. The state has been at the center of several abortion-related lawsuits in the past two years, including a Supreme Court case in June about whether abortions that are performed during a medical emergency are subject to prosecution under the state law. That matter is still pending in the 9th Circuit U.S. Court of Appeals.

During that time, DeVor said she’s discovered other health issues in addition to endometriosis she’s had for many years that may make conceiving a child more challenging.

“I’m just like, man, it is going to be incredibly difficult for us to get pregnant, so that’s one hurdle, and then if something happens, where do we go from there?” she said. “If we have to use IVF or IUI, if I have to travel out of state and spend another 10 or 20 grand to get the care I need, that’s just not feasible.”

DeVor’s husband started a general contracting business in Idaho that has done well, but she said he doesn’t want to risk starting a family in the state either and would rather wait until they can move somewhere she knows her health care will be protected.

“It’s been an interesting experience of moving to a state where people say, ‘We don’t want big government,’ but at the same time telling people, this is what you can and can’t do,” DeVor said.

Idaho economist doesn’t see worrying trends so far in population movement

Though one recent study from the National Bureau of Economic Research said the 13 states with total abortion bans are collectively losing 36,000 residents per quarter based on change of address data from the U.S. Postal Service, it’s unclear how many of those departures are related to politics. According to data from the American Community Survey, nearly 82,000 people moved to Idaho in 2023, while nearly 65,000 moved away, for a net increase of about 16,700 residents.

Jan Roeser, a regional economist at the Idaho Department of Labor, said the state’s population growth has slowed over the past two years, but it had accelerated greatly during the COVID pandemic between 2020 and 2022.

It’s possible that more young people are leaving the state, Roeser said, as seven districts announced or considered school closures in the first half of 2023 because of declining enrollment, according to Idaho Education News. But Idaho is among the eight youngest states in the nation, she said, and one of the leading states for job growth.

“We’d all like to be able to jump up and move just based on our beliefs, but the reality hits that most of us need a job,” Roeser said. “So really, economic opportunity is what I believe allows people to be able to make that final decision, because it’s expensive, and it’s disorienting.”

Until she starts seeing indicators like a spike in layoffs or a decline in enrollment at state universities, Roeser isn’t too concerned about outmigration. But she does worry about the steady decline of fertility rates.

“There’s not much you can do about it, of course, and it takes a long time to reverse once it starts,” she said. “It’s not something you can solve by coming up with public policy.”

Cohen said abortion bans may lead to a small increase in births initially since access is harder to reach, but in the long run, he expects it to contribute more to decreases because it creates uncertainty and fear about pregnancy.

Economically, increasing fertility rates would be a financial drain and potentially hamper growth, he said. That doesn’t mean policies that make it easier to have more children aren’t worth having, but they shouldn’t be done in the interest of increasing births.

“It’s one of the great victories of human development that we allowed people to lower their birth rates,” he said.

‘I’m not going to let them get me down’

For some people, having more children is almost an act of resistance.

Rachel West, a 34-year-old resident of central Texas, had a baby five months ago after a three-year struggle to conceive. She wants at least one more, but knows it might be a stressful experience again because of where she lives. Texas has a near-total abortion ban, along with an attorney general who has attempted to prosecute women who left the state to have an abortion. Cities in Texas have also tried to institute travel bans to prevent women from crossing state lines for abortions.

At the beginning of her pregnancy, West said there were concerns that her embryo was ectopic, when a baby grows in the fallopian tube rather than the uterus. Ectopic pregnancies are not viable and require termination to prevent infection and loss of fertility.

“We did have to think through what that would look like, if we would have to terminate, if we would have trouble finding somebody,” she said. “It was scary, we were just kind of spiraling at home trying to figure out what we would do.”

As someone who struggled to get pregnant the first time, West has also been concerned about efforts to restrict or ban IVF, just in case it becomes an option she has to utilize. But all of the news developments haven’t deterred her from the idea of having another.

“We’ve always wanted to have at least two, maybe three kids, and I would be very frustrated if because of laws in Texas, I had to change my personal life that dramatically,” West said. “It’s almost a prideful thing, where I’m like, I’m not going to let them get me down.”

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U.S. Rep. Mark Pocan (D-Town of Vermont) points to a wall where he has posted printouts listing the budget line items of all the programs reportedly frozen this week after a memo was issued by the Trump administration. (Photo by Erik Gunn/Wisconsin Examiner)

This week’s drama over a federal funding freeze is the precursor to a battle in April over federal tax cuts that Democrats are bracing for, according to U.S. Rep. Mark Pocan.

The Wisconsin Democrat met with reporters Thursday, with most of the session focusing on the move by President Donald Trump’s administration earlier this week to suspend the disbursement of federal grant and loan funds.

Even with a federal court order that’s supposed to be blocking the suspension, Pocan said his office and those of his congressional colleagues are hearing from constituents who have been locked out of funding or are worried about its impact on them.

“We’re getting these calls right now — lots and lots of calls,” Pocan said, including from nonprofits that worry they might have to shut down and from funding recipients who have been shut out from online portals through which they’re supposed to receive payments.

“Even though we’re told it’s not happening, it is happening, and they can’t get the funds that they’re [expecting],” Pocan said.

Pocan, whose district includes Wisconsin’s capital, prepped for the media session by filling a conference room wall in his Madison office with printouts of budget line items affected by the Trump administration’s suspension. He said he got the list of items from a New York Times report.

“When he said he was going to freeze funding to 2,600 different federal lines, that’s what’s [on] the wall right there,” Pocan said.

“We’re getting calls from university researchers” worried about National Institutes of Health grants being frozen, he said. “And if you disrupt research in the middle of it, you’ve lost all the money that you put into some of that research.”

His office has heard from a wide range of other federal funds recipients.

“We’re getting K-12 schools who are still going to lose money for their lunch programs, worried about what they’re going to do — and this is for kids who often this is the only meal that they’re getting during the day,” Pocan said.

Also on the list, he said, are funds that include rural broadband projects, disaster aid, the Small Business Administration and a USDA dairy innovation project — one that Pocan said had bipartisan support from two Wisconsin lawmakers, Democratic Sen. Tammy Baldwin and Republican U.S. Rep. Derrick Van Orden.

How the suspension unfolded echoed what Trump said this past summer, “when he talked in the debate about having a concept of a plan of health care,” Pocan said. “I think pretty much that’s how he operates — he doesn’t have plans, but he has concepts of plans, which often don’t execute.”

At the same time, though, he said the details reflected Project 2025, the Heritage Foundation document that circulated last year as a blueprint for a second Trump term, even though Trump disavowed it during the campaign.

“If you have any question of what they might do, I would look at Project 2025,” Pocan said. “It’s very clear that that is the guiding document for much of what they’re doing.”

Beyond the current turmoil, however, Pocan, a member of the House Appropriations Committee, said the episode foreshadows what Democratic congressional leaders expect will be a major budget  bill in April. They foresee legislation that will extend and magnify the tax cuts that Trump and Congress enacted in 2017, during the president’s first term, and the broad swath of programs caught up in the suspension would be the price, he said.

“This is setting up the cuts for getting funding to give a tax break to those who can afford to go to Mar-A-Lago and the billionaires that were attending the inaugural and all the tech folks,” Pocan said.

“Part of it is just this awful idea that you’re going to cut things that help real people to the degree that you need to” to pay for extending the 2017 tax cuts, he added, pegging the estimate at $4 trillion.

“It would take that, plus they’re talking about lowering the corporate tax rate and a whole lot of other things,” Pocan said. “But everything that’s here is affecting people in the district and across the country for the most part.”

He predicted that the impact wouldn’t be limited to people who don’t support the president. “I guarantee there’s a lot of people who are Trump voters who are going to be very negatively impacted by the cuts that he wants to do in order to give Elon Musk a tax break,” he said.

Congressional Democrats are mapping a three-part response — “litigation, communication — talking about what’s here — and the appropriations process,” Pocan said. “We will probably be doing a lot to highlight this.”

He expects that to be a “the determinative vote for Congress coming up in the Trump administration,” Pocan said. “Because if you vote for a reconciliation bill, it has a giant tax break, and you’re taking that money from lower income folks and people of average income in the district by cutting programs like this.”

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