Do Republicans Realize Whose Health Care They’re Cutting?

Their big beautiful bill is polling terribly, yet somehow Senate leaders may have just made it worse.

(Composite by Hannah Yoest / Shutterstock)

Senate Republican leaders have been unveiling their version of Donald Trump’s “Big Beautiful Bill” bit by bit. And if you thought they were going to dial back some of the sweeping health care cuts from legislation their House counterparts passed last month, boy, are you in for a surprise.

Pretty much every blow to health care that was in the House version of the bill remains in the bill language Senate Finance Chairman Mike Crapo (R-Idaho) released on Monday.¹ And some of the blows could land even harder. Among the few modifications the Senate made are an expansion of “work requirements” for Medicaid and a bigger hit to hospital finances through a change in what are known as provider taxes.²

Official Congressional Budget Office projections had suggested the House bill—which, like the Senate language, also includes big cuts to the Affordable Care Act, a.k.a. Obamacare—would add 11 million more to the ranks of the uninsured while saddling millions more with bigger health care expenses.

The projections for the Senate bill might be even more severe.

What’s remarkable is that there is no reason to think the public wants this. Consider the already-dim assessment of the House version of the legislation, as revealed in a new KFF poll: Sixty-four percent of respondents hold an unfavorable view and just 35 percent hold a favorable one. That finding is consistent with two other recent polls—one from Washington Post-Ipsos, one from Quinnipiac—that found the public opposed to the bill by a similar, roughly two-to-one margin.

The last time major Republican health care legislation drew polling numbers like this was near the start of Donald Trump’s first term in office—i.e., when they were trying to repeal the Affordable Care Act in its entirety while making some additional, radical cuts to Medicaid. In June 2017, just a few weeks before that legislation would fail in the Senate, KFF’s tracking poll found that 30 percent of the public viewed it favorably and 55 percent unfavorably.

Yes, this bill could be even less popular than repeal was.

And the sentiments that the polls picked up back then didn’t fade. They were the first signs of a political backlash against Republicans that was instrumental in Democrats taking back the House in the following November midterms. The bad feelings lingered for years after that and probably helped Democrats to win back the White House and Senate in 2020.

Plenty of currently elected Republicans know this first-hand, because they were around back then and were among those who managed to hold onto their seats. It’s why they spent so much of the past few years saying they weren’t going to go after either Obamacare or Medicaid again—and why they are now downplaying the cuts, or denying they exist, even as they get closer to passing them.

So why press ahead at all? Obviously plenty of Republicans believe in what the legislation would do, because they want to scale back government health care programs and free up dollars they can spend on the big tax cuts that are their top priority.

Also, plenty of Republicans simply don’t want to cross Trump, who has made passing the bill a matter of first importance.

Still, it’s hard to imagine Republicans would be forging ahead in this way if they didn’t think they could avoid the sort of political repercussions they have faced in the past. And while they could certainly be right about that, a closer look at which groups the bill would affect—and when—makes that proposition seem awfully dubious.

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The Republican strategy so far has leaned heavily on speed and obfuscation. The full House voted on legislation just five days after Republican leaders unveiled their bill’s language. The Senate probably won’t move that quickly, but the goal remains to get the legislation a floor vote by July 4, which at this point is less than three weeks away.

That’s barely enough time for analysts to figure out what’s in the bill, let alone explain it to the public—a task Republicans have made even more difficult by packaging so many of the health care cuts as wonky, technical modifications. And it could explain why, according to a recent Navigator survey, more than a third of the country still doesn’t realize Trump and the Republicans are trying to cut Medicaid.

But it’s not just the voting public failing to grasp fully what this legislation would do. Some Republican lawmakers might be missing a few things, too, starting with the fact that Medicaid cuts would hit hard in their own backyards.

Taking hundreds of billions of dollars out of the program would inevitably reduce hospital revenue. And the hospitals least able to absorb that sort of hit are rural hospitals, because so many have come to rely on Medicaid to offset the financial challenges of operating in sparsely populated areas.

In April, the left-leaning Center for American Progress released a report predicting 190 rural hospitals could close because of Medicaid cuts Republicans proposed. It was the first of many such warnings, including a report Democrats recently commissioned from the Sheps Center for Health Services Research.

The researchers at Sheps, which is part of the University of North Carolina, broke down financially vulnerable hospitals by state. And as Democrats noted in a letter summarizing the findings, Alabama, Kentucky, Louisiana, and West Virginia are among the states that could suffer the most hospital losses.

Those are all states with Republican senators, which is surely why the Democrats highlighted them. And it’s fair to wonder whether predictions from a Democratic-aligned think tank or a study commissioned by Democratic senators might be painting a worst case scenario.

But there’s no question that rural hospitals really are in a precarious spot already—or that they would struggle more, with community-wide effects, if they lose additional revenue because of the GOP’s planned Medicaid cuts.

“In your average maternity ward, or your average nursing home, or your average rural hospital, Medicaid is usually the primary payer, the biggest line in the budget,” Anthony Wright, executive director of the advocacy organization FamiliesUSA, said in a phone interview. “If that gets scaled back, that impacts everybody who goes there, regardless of whether they’re on Medicaid per se.”

Wright told me his organization is about to publish a study of its own that documents the “dozens and dozens” of rural hospitals that would be in trouble if these cuts become law.

“Having people covered means more people are paying patients at the providers we all depend on,” said Wright, who spent three decades working on health care access in California and New Jersey before taking on a national job. “Having fewer people covered means less revenue, which means scaled back services or closures for those services already on the brink.”

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It’s not just the legislation’s Medicaid cuts that could give Republicans political problems they may not yet fully perceive.

Both the House bill and emerging Senate version would make significant cuts to the Affordable Care Act by changing the rules for how people sign up for plans on HealthCare.gov and its state counterparts—and then, by changing the financial arrangements that the federal government uses to subsidize coverage.

Like the Medicaid cuts, these changes all sound very technical. But they would have significant consequences, especially if Republicans also allow a temporary boost in insurance subsidies to lapse as planned at the end of the year.

That’d be a double whammy for most of the 24 million people buying Obamacare coverage. And it turns out that 45 percent of them identify as Republicans, while just 35 percent identify as Democrats, according to a separate KFF poll.³ Of the Republicans, more than two-thirds identify as “MAGA Republicans.”

This makes intuitive sense: Relatively more people get private Obamacare coverage in states that haven’t expanded Medicaid yet, because they are less likely to have Medicaid as an option. And all but one of the ten states that have yet to expand Medicaid are conservative-leaning, including three big ones: Florida, Georgia and Texas.

“In the last five years, the number of people getting ACA marketplace coverage has more than doubled—and most of that growth is actually in a relatively small number of Southern red states,” Cynthia Cox, a KFF vice president who directs the organization's ACA project, told me in a phone interview.⁴

On top of that, the premium hikes from GOP legislation cuts and lapsing subsidies would not hit uniformly, because the formula for calculating subsidies takes into account factors like age and local market prices.

“For California, it’s an average increase of 66 percent, but there are pain points in particular areas,” Jessica Altman, executive director of the Covered California marketplace, told me. “Rural areas are hit harder than urban areas because costs are higher there. Older individuals are hit higher than younger individuals.”

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All of this speaks to the particular political peril looming for Republicans from these states—a peril, by the way, that may become manifest a lot sooner than GOP lawmakers realize.

Some people who buy coverage on their own would hear about the price hikes starting in the fall, when brokers and insurers start sending out notices about next year’s rates. Others would discover it on their own when they log on to HealthCare.gov—or state equivalents—to see how much they’ll have to pay for next year’s coverage.

If the prices spike in the way analysts expect, the buyers are going to be angry and looking for somebody to blame.

Democrats learned this the hard way back in October, 2013, when the Affordable Care Act first took full effect—and insurers informed customers they’d be jacking up rates as a result. The resulting backlash was one of the most politically difficult periods of Obama’s presidency.

That is precisely the sort of prospect that would typically spook lawmakers before voting on this bill. For now, almost all elected Republicans seem content to keep going with their big beautiful bill. But they should be spooked—and maybe they will be, once they realize what’s truly in there.

1. The biggest exception appears to be some changes to Obamacare enrollment rules that the current Senate language does not include. But even if these changes don't end up in final legislation, they could happen anyway because the Trump administration has proposed to make them via regulation.

2. There’s a solid argument for addressing these provider taxes, which states use as a budgeting gimmick to draw down extra federal funds. But doing so in the context of a bill that's cutting Medicaid in so many other ways—and without plowing the savings back into health care—would mean even less access to medical care and more financial vulnerability for low-income Americans.

3. This is broadly consistent with analysis from Charles Gaba, who runs the site ACAsignups.net and concluded ACA marketplace cuts were slightly more likely to affect red districts while Medicaid cuts were slightly more likely to affect blue districts—although the real takeaway, he said, is that “tens of millions of Americans in BOTH red and blue districts & states are going to be utterly screwed in the near future, and millions of them will lose healthcare coverage completely.”

4. If you combine the effects of the Medicaid and Affordable Care Act cuts, plus the lapsing ACA subsidies, the five states that would suffer the largest insurance lost coverages—as a percentage of population—would be Florida, Georgia, Louisiana, Mississippi and Texas, according to KFF calculations based on the House bill.