Trump proposed big Medicaid and food stamp cuts. Can he pass them?

Now that it is clear Donald Trump will become president again and will have a Republican Senate and almost certainly a Republican House to back him, it’s important to ask: What will he do with these majorities? And given his track record last time, what will it mean for poor Americans and the programs they rely on?

The last time Donald Trump won the presidency, in 2016, I wrote a piece predicting a huge rollback of the safety net. The Affordable Care Act, with its massive expansion of Medicaid and patient protections, would be repealed; Medicaid itself would see its funding slashed and its guarantee of coverage to poor people eliminated; food stamps would be cut deep and maybe turned over to the states, much as welfare for single parents was in 1996, largely destroying that program.

I was wrong. Trump, and especially then-House Speaker Paul Ryan, did try to do all of that, but in the end enough Republicans realized that repealing the Affordable Care Act wasn’t viable. Medicaid and food stamps survived more or less intact. A Democratic House after the 2018 midterms and, more importantly, a global pandemic, meant that by 2020, the safety net was significantly stronger than it had been in 2016.

I do not know that the same scenario will play out in 2025, and I certainly hope the pandemic part does not repeat. But despite the devastating electoral blow to Democrats, there are reasons for safety net supporters to be optimistic. 

The Senate is solidly Republican but not a total blowout, and four defections would be enough for a bill to fail. With Lisa Murkowski and Susan Collins, who opposed Obamacare repeal in 2017, still in the chamber, it’s not difficult to imagine them and two allies blocking serious changes again. 

The House results will not be known exactly for weeks but look, if anything, closer. And while House Speaker Mike Johnson surely wants to slash the safety net, he is not Paul Ryan. Shrinking government is not his all-consuming passion the way it was for 2017’s House speaker, who once famously said he dreamed of cutting Medicaid while drinking out of kegs as a college student.

Here’s what Republicans might attempt to do to safety net programs, and why achieving it might be difficult.

Health care programs will shrink, but serious cuts will be challenging to pass

On health care, Republicans have one victory that’s more or less baked in. As part of the 2021 stimulus package, Joe Biden and the Democratic Congress adopted expanded subsidies for the Affordable Care Act’s marketplaces. If you were an individual or small business buying private insurance, the tax credits you received to offset premiums were larger. Subsidies were no longer cut off for people making over 400 percent of the poverty line (about $125,000 for a family of four), and subsidies for people below that were made more generous. These provisions were later extended through the end of 2025 as part of the Inflation Reduction Act.

It’s hard to imagine a Republican Congress voting to extend these measures past next year, though insurance companies will certainly lobby for it. Trump’s past budgets have also zeroed out subsidies for private health insurance entirely, which would be a much larger shift.

But subsidies for private insurance are a relatively small part of federal spending on health care. This fiscal year, they amount to $125 billion — very significant, but piddling next to $858 billion on Medicare and $607 billion on Medicaid.

Trump has promised not to cut Medicare, much as he did in 2016, and while his budgets as president did envision spending reductions, they were mostly minor and came from cutting provider payments rather than limiting eligibility.

He did, repeatedly and explicitly, propose cutting Medicaid. The most recent Trump budget to explicitly lay out its plans, for fiscal year 2020, entailed at least $1.1 trillion in cuts to Medicaid and the Affordable Care Act over a decade, per the Congressional Budget Office (CBO). At that time, the agency was projecting $6.2 trillion in 10-year spending on non-Medicare health programs, meaning Trump was calling for a cut of over 17 percent.

Trump waffled on how clear he wanted to be in calling for Medicaid cuts. His 2021 budget was too vague for the CBO to even model. But when he was clear, the proposals had three steps:

• Repeal the ACA’s Medicaid coverage expansion and replace it with a “block grant” for states to spend how they like on health programs.
• Place a “per capita cap” on the rest of Medicaid, meaning states would only be granted a set amount per covered person by the federal government, regardless of what health care they actually received.
• Impose a work requirement, specifically to “require able-bodied, working-age individuals to find employment, train for work, or volunteer” in order to receive Medicaid.

What unites these proposals, especially the per-capita cap and block grant, is that they mean Congress and the White House don’t have to make granular decisions about who specifically is covered and for what. They can simply cut spending and pass decisions on how to spend what’s left to the states. 

Without knowing the exact cap and block grant amounts for the future, it’s hard to say exactly how big these cuts would be, but the Center on Budget and Policy Priorities’ Gideon Lukens and Allison Orris analyzed how Medicaid would’ve been cut if per-capita caps had been put in place in 2018. By 2020, most states would’ve had to slash spending on disabled enrollees (by 12 percent in Pennsylvania and 13 percent in Kentucky); seniors would have seen cuts in 21 states, including cuts of around 17 percent in California; children would have seen cuts in 28 states. 

The point here is not the specific numbers but that the idea can, in practice, amount to very significant reductions in resources for the program.

There is not much room to cut Medicaid without reducing access to the program. Physicians are already paid about 28 percent less by Medicaid than by Medicare, and Medicare in turn pays roughly 22 percent less than private insurers. Medicaid, in other words, pays maybe half of what private insurance pays. Further cuts to prices paid to providers would almost certainly reduce the number who accept the program, making it that much harder for poor people to find care. More likely, states would respond to federal cuts by restricting eligibility and kicking people off the program.

Whether Trump can make these plans a reality depends strongly on what moderate Republicans (like Murkowski and Collins in the Senate and Don Bacon and David Valadao in the House) feel about them. While we don’t know margins for sure right now, it’s looking like Republicans will have 53 Senate seats and fewer than 225 House seats (they need 218 to pass a bill there). That means that even a very small number of defections would be enough to defeat legislation, even legislation that is advanced through the budget reconciliation process and thus needs only 50 Senate votes plus Vice President-elect JD Vance’s tie-breaker.

Murkowski and Collins alone wouldn’t be able to sink a Medicaid cuts bill, but they would only need two other defections to help them. Remember that in 2017, the bill that Sen. John McCain famously killed with them by making a thumbs-down motion on the Senate floor was the so-called “skinny repeal,” which would have only repealed the individual mandate and a few other provisions. The idea was that this bill could then go to a conference committee with the House’s Obamacare repeal bill, where they’d hash out a compromise measure. 

Some Republicans who voted for the skinny repeal, like Lindsey Graham and Ron Johnson, did so only after being promised that the House’s bill, which included deep Medicaid cuts, would never become law. There was rather deep opposition to passing sweeping cuts, even outside the three Republicans who blocked the Senate bill. As West Virginia Republican Shelley Moore Capito said that summer, “I did not come to Washington to hurt people.”

All this suggests to me that getting 50 votes for sweeping Medicaid cuts in the Senate will be rather difficult. More difficult still might be the House, where Republicans will have to defend a number of seats where Harris won and where candidates will not want to enter 2026 midterms with votes to shred Medicaid hanging on them like albatrosses.

Food stamps face brutal cuts

The Supplemental Nutrition Assistance Program (SNAP), colloquially called food stamps, is perhaps the most important safety net program for the very poor. Seventy-five percent of recipients are at or below the poverty line, and over one in five report having no other source of income besides food stamps. The share of single parents living on less than $2 a day is nearly 10 percent before you include SNAP benefits. Food stamps take the number below 3 percent, slashing it by over two-thirds.

Because the program grew out of efforts to prop up crop prices by redirecting “surplus” crops to poor people, it is the province of the Department of Agriculture, and is renewed every five years in a “farm bill” controlled by the House and Senate Agriculture Committees. The last farm bill, that of 2018, expired on September 30 of this year, meaning that writing a new farm bill will be one of Congress’s main priorities early next year.

Glenn Thompson, the Republican chair of the House Ag Committee, released his proposed farm bill in May. Its most striking provision would limit the ability of the Department of Agriculture to update its Thrifty Food Plan, upon which SNAP benefit levels are based. This would amount to a $30 billion cut over a decade, and is a response to the Biden administration updating the Thrifty Food Plan, which resulted in a nearly 30 percent hike in benefit levels.

Trump’s past budgets have envisioned much more sweeping cuts. His last one proposed a nearly 30 percent cut to the program, including new work requirements on top of those already in the program and a plan to shift a big share of the program into a “Harvest Box,” a plan in which households would not get to choose the food they buy but instead be sent a monthly box of shelf-stable foods that the government picks.

Realistically, I suspect the Harvest Box plan in particular will struggle to get traction, in part because major retailers like Walmart and Kroger rely on revenue from customers using food stamps and will fight efforts to redirect funds from them to government provision of food. What’s more, farm bills usually go through regular order, meaning that they’re subject to the filibuster and will need Democratic support in the Senate, which will not be forthcoming for sweeping cuts.

That said, Trump has been consistent about wanting to restrict SNAP as a program and will have Ag Committee chairs in both houses who are broadly on his side. The potential for sharp cuts is definitely present.

The 2021 child tax credit is gone, but the credit might improve all the same

An area where Trump is unlikely to sign sweeping cuts and might even oversee modest expansions is the child tax credit.

Kamala Harris ran on reviving the 2021 version of the child tax credit, which expanded it from $2,000 to as much as $3,600 per child and for the first time made it fully refundable, so poor Americans could benefit even if they were out of work. She also proposed a “baby bonus” of $6,000 to families with newborns.

Those dreams are dead for at least the next four years. But with the 2017 Trump tax cuts expiring next year, including their doubling of the child credit from $1,000 to $2,000, changes are likely coming to the credit all the same. While returning to 2021 is impossible, it’s likely that the end result will direct more money to poor Americans than the credit does under current law.

Republicans have been insistent that any credit include a “phase-in,” or a provision stating that families must have some earnings to receive the child tax credit. But within that framework, they’ve expressed openness to increasing the amount working families receive. 

JD Vance notably called for a $5,000 baby bonus, only to be one-upped by Harris’s $6,000 bid. This past year, Republican Jason Smith, the chair of the tax-writing House Ways and Means Committee, cut a deal with Democrat Ron Wyden, the outgoing chair of the Senate Finance Committee, to expand the child credit by altering the way it phases in. Smith will still be the head tax-writer in 2025 and is likely to push for this provision to stay in.

The complication is that Republicans face a wide array of expiring tax provisions next year, and while some, like incoming Senate Finance Committee chair Mike Crapo, suggest they don’t want to pay for extending those provisions, the reality of higher interest rates (meaning government deficits are now more costly to run) suggests that they probably can’t pass everything they want. Given a wish list that runs from extending those cuts to exempting tips and Social Security income from taxation to letting people deduct interest on car loans, that means that expensive provisions like child tax credit expansions will likely get squeezed. It’s hard to say what exactly will make it into the final package.

One of the least-trumpeted changes of the past half-century is the steady growth of America’s safety net. In 1979, the average lower-income American got $5,300 from government programs aimed at poor people. In 2019, that number was $15,800. America’s commitment to poor people more than tripled, and the result was a marked reduction in poverty. Trump’s reelection threatens that trend. But his first term, and those of Presidents Bush and Reagan before him, were not enough to reverse it. There are reasons to think it could continue even through the next four years.