Portside

The following is a guest post for the “Trump’s Beautiful Disaster” newsletter by Thom Walsh, a member of the Green Mountain Care Board, Vermont’s regulatory system for health care.

Earlier this month, the Vermont Association of Hospitals and Health Systems warned that the Senate’s budget bill could cost Vermont hospitals more than $1.7 billion over five years. That’s in a state where many hospitals are already operating at a loss. The threat isn’t just to patients. It’s to jobs, local economies, and community anchors.

Vermont isn’t alone, and neither is Congress in savaging the health care system. In Missouri, over 30,000 children lost Medicaid coverage in 2023—many due to paperwork problems or system delays. In Mississippi, lawmakers advanced a bill to overhaul Medicaid eligibility systems, despite the state’s limited administrative capacity. Across the country, these changes are pitched as efficiency or modernization. But their effects are cumulative—and massive.

What’s happening to Medicaid isn’t overt. It’s incremental and strategic. The Senate’s latest proposal, far from softening the blow from the House’s version, includes a cap on provider taxes, reinstatement of co-pays, and expansion of work requirements for parents. These measures aren’t labeled as Medicaid cuts, but their purpose and effect are exactly that. And because they’re framed in the language of efficiency and fiscal discipline, they often escape public notice. That’s by design.

Rebranded, Reframed, and Reduced

The reality is that many people don’t know they’re on Medicaid. Over the years, many states have rebranded the program to distance it from national politics. Oklahoma calls it SoonerCare. Arkansas uses ARHOME. Connecticut’s program is HUSKY Health. Tennessee has TennCare. These names make Medicaid more palatable locally—but also more vulnerable. When coverage is lost or eligibility is tightened, beneficiaries often don’t realize what they’re losing. The branding creates political insulation.

In Arkansas, polling shows broad support for the coverage ARHOME provides—but far less support for “Medicaid” as a term. That disconnect lets lawmakers publicly praise ARHOME while voting to restrict its eligibility or quietly reduce oversight. The rebrand becomes a shield, obscuring the source of the program’s success and making it harder to trace the consequences of its decline.

At the same time, federal and state policymakers have developed a policy vocabulary built to obscure. “Flexibility.” “Eligibility integrity.” “Provider alignment.” “Cost-sharing.” Behind these phrases lie real reductions in access, funding, and system stability. As these reductions compound, so does the gap between what the public thinks Medicaid is and what it actually does.

Expanded work requirements are among the most effective tools in this stealth strategy. The Senate proposal extends work requirements to parents of school-aged children. At face value, the policy sounds plausible—who could oppose encouraging work? But experience tells a different story.

In Arkansas’s short-lived 2018 Medicaid work requirement pilot, more than 18,000 people lost coverage. Most were working. They just couldn’t keep up with confusing reporting requirements, poor internet access, or inconsistent job schedules. In many cases, they didn’t even know their coverage was at risk. The system wasn’t built to promote work. It was built to reduce enrollment.

We’ve seen through the years that administrative “friction” is a powerful policy lever. Churn replaces continuity. Preventive care is delayed. Diagnoses are missed. Parents lose access, and children follow. Hospitals, schools, and public-health departments are left to pick up the pieces.

According to the Center on Budget and Policy Priorities, red tape has become a primary mechanism for reducing enrollment. For example, when states froze automatic redeterminations during COVID, coverage rates stabilized. But now, with the “continuous coverage” freeze lifted, disenrollment is rising, with cuts to the program smuggled in under the guise of “program modernization.”

The Centers for Medicare & Medicaid Services found that more than 70 percent of children losing coverage during the unwinding of the COVID continuous coverage requirement were removed not because they were ineligible, but because of missed mail, incorrect forms, or hard-to-navigate renewal systems. These breakdowns aren’t accidental. They’re a feature of a system designed to deter participation.

Medicaid Is Infrastructure

Medicaid is not a marginal welfare benefit. It’s infrastructure. It’s the connective tissue of the U.S. health care system. Its footprint is wide, but its visibility is low. That’s what makes it so easy to cut, and so dangerous to weaken.

Many beneficiaries don’t realize that the programs they rely on—like home health services for an aging parent, behavioral health access, or school-based mental health support—are funded through Medicaid. Many don’t know that Medicaid pays for 41 percent of all births, and supports over 30 percent of all behavioral health funding. Many are unaware that it is the largest payer for long-term care.

Medicaid keeps hospitals open, stabilizes state budgets and individual insurance premiums, supports long-term care systems, and makes behavioral health treatment possible in underserved communities.

Like clean water or working roads, we don’t talk about Medicaid when it works. But we will notice when it fails. And when Medicaid is quietly eroded, it doesn’t take long for the system to show cracks.

Hospitals are among the first to feel it. Especially in rural areas, where margins are already thin, even modest changes in reimbursement or enrollment can be catastrophic. According to a report from the Center for Healthcare Quality and Payment Reform, over 25 percent of rural hospitals are at risk of closure nationwide, and in 11 states, that number rises to 50 percent.

Data from KFF shows that the hospitals at most significant risk of failure are in red states that have refused to expand Medicaid. Negative margins are more common among rural hospitals in the most remote areas. That means cuts to Medicaid won’t just affect outliers—they’ll hit the most vulnerable institutions in the least-protected communities.

Everyone Pays

When these facilities close, the consequences ripple outward: job losses, longer emergency response times, reduced access to prenatal care, and fewer behavioral health services. And the ripple effects don’t end at the hospital doors.

When providers face revenue shortfalls, they will raise prices charged to commercial payers, if they have the market power to do so. And if there are fewer hospitals serving patients, that market power will rise. That means higher premiums, deductibles, and cost-sharing. Employers struggle to offer affordable plans. Small businesses shrink or close entirely. Families tighten their budgets to absorb the difference. Some go bankrupt.

In this way, Medicaid isn’t just a safety net for the poor—it’s an invisible subsidy for everyone. When it shrinks, costs don’t disappear. They move to households, employers, local governments, school systems, ERs, jails. Everyone pays.

The people most likely to bear the burden are often the least likely to recognize the source. Because the cuts are obscured—by branding, language, and bureaucracy—the link between cause and consequence is broken.

Public Will, Political Evasion

Earlier this month, a survey commissioned by the Milbank Memorial Fund found that 75 percent of Americans want Medicaid funding maintained or increased. Two-thirds reported a personal connection to the program. More than half said they’d be willing to contact their elected officials to oppose cuts.

But the cuts continue, precisely because they are masked. Provider tax caps sound like technical adjustments. Work requirements sound like incentives. Reduced enrollment eligibility sounds like accountability. None of these terms reveal the outcome: fewer people covered, less financial stability for providers, and higher costs for the rest of us.

Even in news coverage, these proposals are seldom framed as Medicaid cuts. This failure in framing complicates public response and makes it more challenging for advocates to organize.

What We Can Do

How can we prevent this damage? Step one: linguistic clarity. Provider tax caps are Medicaid cuts. Reinstated co-pays are Medicaid cuts. Work requirements are Medicaid cuts. Labeling matters. If we can’t name what’s happening, we can’t build opposition—or propose alternatives.

Step two: reclaim Medicaid’s identity. SoonerCare is Medicaid. TennCare is Medicaid. HUSKY Health is Medicaid. “Dr. Dynasaur” refers to Medicaid-funded health coverage for children and teens in my state of Vermont. When these programs are cut, people suffer—even if they don’t know what to call it.

Step three: reframing the public conversation. Medicaid is not just for someone else; it protects us all—whether through our hospitals, family caregivers, or insurance rates. To defend it, we must start discussing it for what it truly is: a public good, an economic stabilizer, and a moral commitment.

Step four: organizing policy response. That means requiring states to disclose coverage impact estimates when pursuing administrative changes. It means restoring federal guardrails that prevent states from using administrative burdens as a backdoor cut. It means tracking rebranded programs and holding them accountable for transparency and continuity.

When public programs become unrecognizable, they become indefensible. Medicaid’s survival relies not only on budgets but also on public understanding. That makes language—not just legislation—the front line in this battle.

Medicaid’s dismantling isn’t occurring by accident—it’s happening by design. However, naming it for what it is—cutting Medicaid—is the first step in resisting. By calling these budgetary tweaks and administrative hurdles by their true names, we empower people and policymakers to take action. We must ensure recognition, transparency, and the civic infrastructure that connects Medicaid to the lives it impacts.

Many hoped that after the House passed a proposal for deep Medicaid cuts, the Senate would intervene to soften the blow, protect the most vulnerable, and stabilize a fractured system. But no one is coming to save Medicaid—not unless the public sees these policies for what they are and demands something different.

Thom Walsh, Ph.D., M.S., is a member of Vermont’s health care regulatory body, the Green Mountain Care Board, and a lecturer at Dartmouth’s Geisel School of Medicine and Tuck School of Business.