The final time a Republican-controlled Congress and President Donald Trump moved to slash Medicaid spending, in 2017, a key political drive stood of their approach: GOP governors.

Now, as Congress steamrolls towards passing historic Medicaid cuts of about $1 trillion over 10 years by means of Trump’s tax and spending laws, purple state governors are saying little publicly about what it does to well being care — whilst they face reductions that can punch multibillion-dollar holes of their states’ budgets.

Medicaid, a program collectively run by states and the federal authorities, covers greater than 70 million low-income or disabled individuals, together with almost half of the nation’s kids. Republicans say the $900 billion-a-year program was allowed to develop too massive below Democrats Barack Obama and Joe Biden by including nondisabled adults they are saying do not deserve authorities help, they usually have lengthy sought to scale it again.

Among the greatest well being cuts within the laws Trump calls the “One Massive Lovely Invoice” are achieved by means of new insurance policies that would scale back enrollment by imposing extra paperwork calls for on enrollees, together with a requirement that many show they’re working. These insurance policies would have an effect on solely states that expanded Medicaid to extra low-income individuals below the Inexpensive Care Act.

Nineteen of these states are led by Republican governors. Their silence on the invoice’s well being measures is giving political cowl to GOP lawmakers from their states as they search to chop Medicaid protection for hundreds of thousands of people that gained it throughout the final decade.

KFF Well being Information contacted all 19 governors for touch upon the laws’s Medicaid cuts. Solely six responded. Most mentioned they backed imposing a piece requirement on grownup Medicaid enrollees.

“Implementing work necessities for able-bodied adults is an efficient and obligatory reform in order that Medicaid is getting used for non permanent help and never a everlasting entitlement,” mentioned Drew Galang, a spokesperson for Gov. Patrick Morrisey of West Virginia.

“Governor Rhoden helps workforce participation as a requirement of Medicaid growth eligibility,” mentioned Josie Harms, a spokesperson for South Dakota Gov. Larry Rhoden, including that congressional lawmakers have the governor’s assist: “South Dakota has a superb federal delegation, and Governor Rhoden trusts them to struggle for South Dakota’s priorities whereas delivering on President Trump’s guarantees.”

In an indication of how the political winds have modified, not one of the governors mentioned something concerning the laws’s crackdown on one other vital lower, to supplier taxes — a device that almost all of their states use to assist pay their share of Medicaid and achieve further funds from the federal authorities. That change is anticipated to price states billions.

A bipartisan subject now not

In distinction to the radio silence from GOP governors, Democratic governors have campaigned in opposition to the megabill for weeks.

Pennsylvania Gov. Josh Shapiro posted on the social media platform X that Trump and congressional Republicans had been deceptive People by saying they had been slicing solely waste, fraud, and abuse in Medicaid.

“They’re speeding to kick tons of of hundreds of Pennsylvanians off their healthcare — and mendacity about it,” he posted. “The harm this can do right here in Pennsylvania and throughout America is staggering and will likely be felt for years to return.”

In New York, Gov. Kathy Hochul on July 1 charged that Trump’s laws would devastate hospitals and will result in greater than 34,000 job cuts in her state.

“The collective affect of the GOP reconciliation invoice in Washington, D.C., might drive hospitals to curtail critically wanted companies corresponding to maternity care and psychiatric remedy, to not point out to downsize operations, and even shut fully,” she mentioned in a press release.

In 2017, the refrain was bipartisan, as Republican governors in Ohio, Nevada, and Massachusetts spoke out in opposition to slicing Medicaid. Trump’s invoice to repeal a lot of the Inexpensive Care Act and roll again its Medicaid growth narrowly failed within the Senate.

“It has been stunning that red-state governors, notably these in Medicaid growth states, have not spoken out in opposition to Medicaid cuts,” mentioned Larry Levitt, government vice chairman for well being coverage at KFF, a well being data nonprofit that features KFF Well being Information. “Republican governors had been a potent political drive within the failed 2017 effort to repeal and exchange the ACA, together with Medicaid growth.”

What’s modified since 2017, coverage specialists say, is that there are fewer average Republican governors, and GOP state executives who advocated for Medicaid growth over a decade in the past are now not in workplace.

Moreover, seven of the then-red states that expanded Medicaid did so through poll initiative, largely over opposition from their governors.

In truth, the Medicaid work requirement is backed by many Republican governors, even when it means much less federal Medicaid cash and results in fewer individuals coated.

A number of states, together with Arkansas and Ohio, have already handed state legal guidelines to implement a requirement that adults enrolled below the ACA’s Medicaid growth work, volunteer, go to highschool, or take part in job coaching. Most states have but to deliver work requirement packages to fruition as a result of they’re ready for federal authorities approval.

Charles “Chip” Kahn, president of the Federation of American Hospitals, a commerce group of investor-owned hospitals, mentioned that whereas fewer governors have engaged publicly in making an attempt to dam Medicaid cuts below the invoice, federal lawmakers are listening to from legislators of their states.

A political dilemma for Republican governors is that, not like in 2017, the invoice earlier than Congress is just not laws aimed expressly at repealing Obamacare. Its scope is broader than well being care, and would lengthen lots of Trump’s tax cuts, and direct billions in new spending towards border safety, immigration enforcement, and the navy, whereas additionally slicing well being care spending.

“It is like enjoying multidimensional chess somewhat than specializing in one subject,” Kahn mentioned.

Larry Jacobs, director of the Heart for the Research of Politics and Governance on the College of Minnesota, mentioned some Republican governors could have expressed considerations privately to their states’ GOP senators however usually are not talking out publicly for concern of drawing Trump’s wrath.

“Why are they being cagey? Trump and never desirous to be ‘Liz Cheney’d,'” Jacobs mentioned, referring to the Republican former Wyoming lawmaker whom Trump helped oust after she served as vice chair of an inquiry into his makes an attempt to overturn the outcomes of the 2020 election.

Strolling political tightropes

The political peril Republican lawmakers face in publicly difficult Trump stays express. On June 29, Sen. Thom Tillis (R-N.C.) introduced he wouldn’t run for reelection after he voiced considerations concerning the invoice and the president threatened to again a main challenger. Tillis was one among three GOP senators to vote in opposition to it on July 1, although it nonetheless narrowly handed.

Along with the work requirement, the most important Medicaid cuts within the invoice stem from its restrictions on supplier taxes — levies that states impose on hospitals, nursing houses, and different well being care establishments to assist enhance their federal reimbursement. A lot of the extra cash is then returned to the well being care suppliers within the type of increased funds for his or her Medicaid sufferers.

The follow, which has been adopted in each state however Alaska, has been criticized by some Beltway Republicans as “cash laundering” — though the taxes are permitted by state lawmakers and the federal Facilities for Medicare & Medicaid Companies and have been allowed below federal legislation for many years.

The Senate invoice would restrict the cash states might elevate — a transfer that will imply billions in funding cuts to states and their hospitals.

The states with Republican governors that expanded Medicaid are Alaska, Arkansas, Idaho, Indiana, Iowa, Louisiana, Missouri, Montana, Nebraska, New Hampshire, Nevada, North Dakota, Ohio, Oklahoma, South Dakota, Vermont, Virginia, West Virginia, and Utah.

One of many governors who expressed considerations about repealing the Obamacare Medicaid growth in 2017 was Jim Justice of West Virginia, a Democrat on the time.

In a June 2017 letter to West Virginia Sen. Shelley Moore Capito, a Republican, Justice wrote: “Since so lots of our individuals depend on Medicaid, any lower to Medicaid would destroy households in West Virginia.” He added that “the implications can be past catastrophic.”

On July 1, Justice — elected to the Senate as a Republican final 12 months — voted for Trump’s megabill, together with its Medicaid cuts.

“The Senator believes this invoice strikes an excellent stability between defending probably the most susceptible and people who depend on this system whereas rooting out waste, fraud, and abuse to make sure this system is run effectively for these deserving,” William O’Grady, a Justice spokesperson, mentioned in an electronic mail Wednesday.

KFF Well being Information correspondent Arielle Zionts contributed to this report.

KFF Well being Information is a nationwide newsroom that produces in-depth journalism about well being points and is likely one of the core working packages at KFF.