By John Wilkerson

With former President Trump headed back to the White House, the U.S. Medicaid program, which covers medical care for people with low incomes, could face cuts. 

But Medicaid’s transformation to a program mostly run by private insurers adds an influential industry to its list of guardians, alongside the rural hospitals that rely on the program to balance their budgets.

The threat to Medicaid emerges, in part, from simple math. Republicans are likely to go looking for some major places to cut spending to help fund a plan to extend Trump’s 2017 tax cuts, which expire after next year. When Republicans passed the tax cut legislation, the Congressional Budget Office estimated that the tax cuts would add $1.8 trillion over a decade to the deficit. 

Trump has already promised to not touch Medicare or Social Security, and has called for increasing the defense budget. Medicaid is just about the only large government program left, and Trump has made no similar promise to preserve it.

“Trump’s silence on Medicaid is in some ways the best indication that Medicaid will have a target on its back,” said Larry Levitt, executive vice president for health policy at KFF. 

Trump Campaign National Press Secretary Karoline Leavitt declined to say whether Trump is open to cutting Medicaid spending. She instead said Trump’s plan to deport unauthorized immigrants would reduce the financial drain on public health care programs.

The nonpartisan Congressional Budget Office estimated that spending on emergency Medicaid services for noncitizen immigrants, whether in the United States legally or not, was $3.8 billion in 2023, which was 0.4% of total Medicaid spending that year.

Medicaid will be especially vulnerable if Republicans control both the Senate and House because that would enable them to avoid the Senate filibuster by using a budget process that requires only a simple majority to pass. Republicans will control the Senate. They already won 52 seats, and six more races have yet to be called. It’s still not clear which party will control the House.

Veda Partners said it’s not clear that Republicans could pull off major Medicaid spending cuts, but the independent research firm noted that Republicans would have an easier time of it if they win more seats.