Sign up for the Slatest to get the most insightful analysis, criticism, and advice out there, delivered to your inbox daily.

At long last, the time has come for House Republicans to answer the $880 billion question. That’s the amount in cuts that the Energy and Commerce Committee, which oversees Medicaid, must find to help cover the cost of President Donald Trump’s “one big, beautiful bill” comprising his legislative agenda.

For months, as Republicans in the House and Senate negotiated “blueprints” and “frameworks” ahead of the actual bill-writing process, they punted on exactly which changes they’d make to Medicaid. It’s a delicate subject. It puts House Republican factions at loggerheads, as spending hawks insist on substantial cuts to the health coverage program for the poor and needy, while swing seat members worry that such cuts will cost them their seats. And Democrats have been preparing since Election Day 2024 to obliterate Republicans for slashing Medicaid while giving tax cuts to the rich.

But they can’t dance around the question any longer. And although the Energy and Commerce Committee hasn’t yet released a draft of its portion of the legislation, or even made its final decisions, the envisioned cuts are coming into view. And the target is, unmistakably, the Affordable Care Act’s Medicaid expansion, which provides health coverage to 20 million people.

“Traditional” Medicaid focuses primarily on covering the most vulnerable low-income populations, like children, parents, caregivers, pregnant women, and disabled people. The cost is split between the federal government and states, and there’s a formula, based largely on states’ per capita income, to determine the feds’ share of the bill. It varies roughly from 50 and 75 percent, again, for traditional Medicaid.

Obamacare, now more than 15 years old, expanded Medicaid by making those who earn up to 138 percent of the federal poverty line eligible for the program. Crucially, it enticed states to accept the expansion by promising that the feds would cover 90 percent of the costs for these new enrollees. Under that generous financial arrangement, 41 states and the District of Columbia have expanded Medicaid.

If you’ve read between the lines of Republicans’ rhetoric in recent weeks, they’ve carefully left the door open to significant cuts to the Medicaid expansion. House Speaker Mike Johnson, when asked about potential cuts, typically begins by laughing off the suggestion, then explains that they’re merely going to “root out fraud, waste, and abuse” in the program. In his mind, that includes “able-bodied workers” and “young men” who “should never be on the program at all.”

“When you have people on the program that are draining the resources, it takes it away from people that are actually needing it the most and are intended to receive it,” Johnson said in a Fox News interview in mid-April. “You’re talking about young single mothers down on their fortunes at a moment, the people with real disabilities, the elderly, and we’ve got to protect and preserve that program. So we’re going to preserve the integrity of it in this process.” Here, he’s drawing a bright line between expansion enrollees who might be “draining the resources” from those on traditional Medicaid.

Even the House moderates, who earned headlines for a mid-April letter supposedly warning their leaders against pursuing big Medicaid cuts, still left themselves plenty of space to pursue expansion cuts. “We cannot and will not support a final reconciliation bill,” the dozen members wrote, “that includes any reduction in Medicaid coverage for vulnerable populations.” Those last three words—for vulnerable populations—are key, suggesting that their line is drawn only at reducing coverage for traditional Medicaid.

So how do Republicans target the Medicaid expansion? Right now, they’re looking at a couple of different approaches to get the big savings they would need.

The first would be to do away with the expansion’s 90 percent federal match rate and offer expansion states the same federal match rate they get under traditional Medicaid. That would reduce the deficit by $561 billion over 10 years, getting the committee most of the way to its $880 billion target. Their argument for this is that it’s unfair for states to get a better deal covering “able-bodied” people who are simply poor than for their most vulnerable populations.

“We have an expansion population that gets 90 percent federal money, and you have traditional [Medicaid], so a disabled child in Kentucky gets 72 cents when they go to the doctor. And we know that’s just unsustainable,” Energy and Commerce Chairman Brett Guthrie told NBC News on Monday.

The other element of the spin is that they wouldn’t be kicking people off Medicaid with this change. Why, were anyone to be kicked off, that would be the choice of individual states.

Jim Newell Read More

“Nobody would be kicked off Medicaid as long as the governors decided that they want to continue to fund the program,” Georgia Rep. Austin Scott, another committee member, said on Fox last week. “And so we are going to ask the states to pick up and pay some additional percentage of Medicaid.”

But “picking up” more of the cost was not part of the deal. States took up the expansion only because of the 90 percent match rate—indeed, that’s why the match rate was set up at 90 percent: to give states an offer they couldn’t refuse to help achieve Obamacare’s goal of near-universal health coverage. At this moment, in fact, 12 states have trigger laws that would end or amend the expansion were the federal share to dip below 90 percent.

It’s partially because of these laws that negotiators are now reportedly leaning toward the second approach: per capita caps for the expansion population. Capping the amount of funds states receive per expansion enrollee, as Guthrie told Axios on Monday, “takes away the open-ended checkbook.” The cap could be adjusted to produce whatever savings target the committee has in mind.

This Content is Available for Slate Plus members only I Think the Tide Is Finally Turning Yes, Canada’s Election Was Enormously Influenced by Trump. No, It’s Not As Good As It Seems. They’re Donald Trump’s Most Loyal Voters. I Didn’t Understand Why. After a Weekend in the Woods With Them, That Changed. I Went to Two Democrat-Run Events in GOP-Held Districts, Back to Back. What I Saw Was Telling.

The political issue, though, would be the same: If you make a major reform to Medicaid that strips it of hundreds of billions of dollars over 10 years, plenty of poor people are going to either lose their health coverage or get a worse version of it.

This can’t be spun away. Republicans can’t say they’re cutting “waste,” or that they’re finding administrative efficiencies, or that it’s the mean old governors who would be kicking people off. There will come a point when House Republicans pursuing this path have to attempt to make an honest case for what they’re doing: that Medicaid spending has grown too sharply, and flattening its trajectory is necessary as the government approaches $40 trillion in federal debt and rising borrowing costs. (Also, because they need the cash for delicious tax cuts.) This argument wouldn’t make people happy, but it would be less insulting to the intelligence than arguing that they’re just trimming the hedges a bit. Instead, they’re talking about taking out trees. People will notice.

Get the best of news and politics Sign up for Slate’s evening newsletter.