Why Republicans' proposed health care cuts could be politically risky

The Trump administration and new Republican majority in Congress have big plans to extend tax cuts and crack down on immigration. To pay for these changes, they're in the market to cut government spending by trillions of dollars, and government-assisted health care programs are among their first targets. Earlier this month, a House Budget Committee memo and detailed list, both obtained by Politico, laid out potential budget cuts, including savings of up to $2.3 trillion from funding for Medicaid, the government program that provides health insurance for low-income adults and children; and an additional $1 trillion or so in other cuts from Medicare, the equivalent federal program for older adults, and other health care-related programs.

Other moves from the administration this week have raised alarm bells for Medicaid as well. Even though President Donald Trump's move to freeze funding for all federal grants and loans (which has been halted by a federal judge) was not intended to impact benefits programs, a brief outage in the Medicaid payment system heightened concerns and confusion over the program's future under his administration. Meanwhile, Trump's nominee to head the Department of Health and Human Services, Robert F. Kennedy Jr., lambasted high medical costs during his confirmation hearing, and seemed to pin the blame on government-run programs. He claimed Americans don't like Medicaid and most would prefer to be on private insurance plans.

Health care generally wasn't the top issue voters considered when casting their votes in November, as their concerns over the economy and immigration propelled Trump back into office. Nonetheless, voters across the political spectrum are broadly unhappy with the state of health care and health insurance. A recent poll from PerryUndem/YouGov dove into how exactly Americans felt about the U.S. health care system and some of the proposed cuts put forth by Republicans.* The results show that Americans share Kennedy's anger at the health care system — 39 percent said they were very frustrated and 38 percent said they were somewhat frustrated with the state of the current health care system.

Unsurprisingly, high costs were a major concern for those surveyed. Seventy-eight percent said health care was currently very or somewhat unaffordable for most people, and 63 percent said it was personally important to them that "something be done soon to make health care more affordable." Nearly half of survey respondents said they have at some point had medical debt from receiving health care services for themselves or a family member, while more than 4 in 10 said they had skipped receiving medical care or prescriptions because of cost. This is despite the fact that the vast majority of Americans now have some kind of health insurance, whether it's private or government-sponsored. (Fifteen percent in the PerryUndem/YouGov survey said they did not currently have coverage, a bit higher than the Census Bureau's estimate of roughly 8 percent of the total population in 2023.)

But while Americans in the survey agreed with Kennedy that health care costs are too high and the health care system needs changes, they decidedly did not agree with where he pointed the blame; government-sponsored health care programs like Medicaid remain widely popular.

In his 2024 campaign, Trump's promises on health care were vague, as he now-famously said in his sole debate with former Vice President Kamala Harris that he had "concepts of a plan." As the details of that plan continue to take shape, Americans will likely be open to changes to a system they see as deeply flawed and too expensive, but Republicans' proposed budget cuts and changes to government-run programs could rub them the wrong way.

Most Americans oppose cuts to Medicaid

To begin with, the government programs on Republicans' chopping block don't have the same low approval as health care in general. Eight in 10 Americans had a favorable view of Medicaid (which was additionally described in the survey as "a joint federal and state health care program that covers low-income families and children, pregnant women, older adults, and people with disabilities"). Contrary to Kennedy's claim that Americans dislike Medicaid and would prefer to be on private insurance, approval of the program was even higher (around 90 percent) among those who were or had previously been enrolled in it. This is in line with other surveys that have found Americans generally approve of the Medicaid program.

When asked whether funding for Medicaid should increase, decrease or remain the same, Americans decisively favored continuing or increasing program funding: Forty-nine percent said funding should be increased, and 40 percent said funding should be kept at current levels, while only 12 percent said it should be decreased.

Of course, Republicans haven't proposed across-the-board cuts to Medicaid, but instead a wide range of targeted cuts or program restrictions that would reduce overall program spending and limit who is eligible to enroll. The survey asked how Americans felt about some of those specific changes and found that most were net unpopular with Americans, though a large share also remained undecided.

One of the most high-impact options floated by House Republicans is establishing per-capita caps on the amount the federal government pays per person enrolled in Medicaid. That idea was supported by only 21 percent of Americans and opposed by 53 percent. Even among Republicans, slightly more opposed the cuts than supported them (36 percent to 35 percent). Support was lower for a potential reduction in funding to the 41 states (and Washington, D.C.) that expanded Medicaid eligibility under the Affordable Care Act, which could remove eligibility for millions of those enrolled in the program: 18 percent supported and 55 percent opposed those funding cuts, and once again opposition still outweighed support among Republicans (36 percent to 31 percent). And the numbers were even less favorable for a general proposal to remove protections that guarantee Medicaid coverage to certain populations, like low-income pregnant women and disabled Americans.

One GOP proposal that could be popular, though, is requiring Medicaid recipients to prove they are employed in order to keep their benefits: 38 percent overall said they would support it, compared to 35 percent who were opposed. And it was notably more popular among Republicans, with 57 percent in favor and 18 percent opposed. Republicans have long advocated for work requirements for many public benefit programs, and Arkansas even enacted a Medicaid work requirement in 2018 — it was struck down by a federal judge shortly thereafter, though Gov. Sarah Huckabee Sanders plans to try again under the new administration.

The ACA has grown in popularity

Beyond expanding Medicaid eligibility to millions of lower-income Americans, the Affordable Care Act made sweeping changes to health insurance access, including by making it illegal for health insurance companies to refuse to cover preexisting conditions, requiring them to allow children to stay on their parents' plans until the age of 26 and opening state-level health care insurance marketplaces to allow people to buy plans with government subsidies.

Republicans have tried dozens of times since the Affordable Care Act was passed in 2010 to repeal it. After the latest failed attempt during his first term, Donald Trump has distanced himself from his earlier promises to do so, as have Republicans as a whole. Rather than fully repeal the law, though, Republicans' proposed budget cuts are among the ways they could scale it back or reduce its effectiveness, including by forcing states to trim coverage due to reduced funding, or simply by doing nothing: a Biden-era law that extended tax credits for individuals to buy insurance plans on their state ACA marketplaces is set to end in 2025.

Pivoting away from a full ACA repeal is probably politically wise for Republicans, as the law has actually gained popularity in the more than 10 years since it went into effect. Seventy-three percent of those surveyed had a favorable opinion of the law, including 52 percent of Republicans. At the start of the survey, 32 percent of respondents said they'd support repealing the law, while 44 percent opposed a repeal. After completing the full survey that described specific provisions of the ACA, though, the share of respondents who favored repealing it dropped slightly, to 28 percent. The biggest change was among Republicans, 59 percent of whom initially said they supported a repeal, compared to 49 percent later in the survey.

Even fewer Americans supported repealing popular aspects of the law that Republicans have previously tried to target, with only 25 percent in favor and 47 percent opposed to a proposal to let health care plans that offer reduced benefits into the marketplace, a change previously made by the first Trump administration but repealed by President Joe Biden — and potentially something in line with Kennedy's calls to expand affordable private options. Other changes that were included in the GOP's last attempt to kill the ACA were even less popular: around 7 in 10 Americans opposed changes that would allow insurance companies to "charge sicker people more for their health insurance or deny them coverage" or to "charge women more than men for their health insurance." Meanwhile, half of Americans said Congress should extend the expiring individual tax credits toward health insurance, while only 16 percent said Congress should end them to reduce government costs. (The question wording noted that these credits "made health coverage more affordable for more than 19 million people.")

Perhaps most tellingly when it comes to Americans' support for government-sponsored health care programs, a majority of Americans, 55 percent, said they would somewhat or strongly support a government-sponsored plan that could compete with commercial insurance plans — an idea that rose to prominence when it was championed by progressive Democrats and ultimately backed by President Barack Obama in the debates over what became the Affordable Care Act. Commonly referred to as "the public option" at the time, the idea was ultimately scrapped by Democrats to win over independent Connecticut Sen. Joe Lieberman, whose support they needed to pass the law along party lines. Since then, the idea of giving Americans access to a government-sponsored plan — whether through a new government program or by allowing all Americans to buy into Medicaid regardless of income — is still backed by many Democrats, but has mostly faded from public debate.

The idea remains very popular among Democratic voters, though, and seems to have a substantial base of support among Republicans as well: 71 percent of Democrats and 45 percent of Republicans said they would strongly or somewhat support a government-sponsored health plan. And perhaps because it wasn't actively proposed or opposed during the 2024 campaign, very few voters were against the idea, while many were undecided: only 13 percent of respondents opposed it, while 32 neither supported nor opposed. That undecided number was particularly high among Republican and independent voters, more than one-third of whom said they would neither support nor oppose the plan.

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That last point illustrates a common theme in this survey: Many Republicans haven't decided how they feel about some of the health care questions that may be central to the coming debate on government spending.

While Democrats in the poll were fairly united in their opposition to proposed changes to federal health care spending and programs, Republicans often had divided opinions, and on certain questions, many had no opinion at all. For example, 38 percent said they neither supported nor opposed cutting Medicaid spending by reducing block grants to states, 33 percent neither supported nor opposed reducing funding to Medicaid expansion states and 30 percent said the same about per capita funding caps.

Similarly, around 29 percent of Republicans said they neither supported nor opposed repealing the Affordable Care Act — and the number is a bit higher among 2024 Trump voters, 32 percent.

Overall, this could signal a "wait and see" approach among Republicans and Trump supporters. The nitty-gritty debate over whether or what health care provisions Republicans may propose cuts to is only just beginning. But even if health care wasn't a top priority for these voters in deciding their votes in 2024, their opinions are likely to solidify as the debate continues. Republicans seem to have their work cut out for them when it comes to winning over public opinion.

Footnote

*This was a national survey conducted Dec. 13 to 23, 2024, among 1,269 adults 18 and older.