President Trump’s decision to rescind the broad freeze on federal grant funding shows that his administration is not impervious to public blowback and media scrutiny. Could he walk away from controversial health policy proposals percolating in the Congress if they prove unpopular?

I wrote previously that President Trump’s silence on Medicaid during the campaign could have significant implications. He pointedly said he would not cut Medicare or Social Security and wanted to build up U.S. defense capabilities. Therefore, the logic goes, if Republicans want to pay for their tax cuts, they have no choice but to follow the money and back the Brinks truck up to Medicaid, the next largest part of the federal budget. The early signs on Capitol Hill suggest they are doing that. Proposals being floated in the House would cut a prodigious $2.3 trillion out of Medicaid spending over the next 10 years, or nearly one third of Medicaid spending. It’s 22% of all federal funding for the states.

But there’s a flip side to Trump’s silence—it gives him flexibility to walk away. He is famously transactional and not committed to any specific policy positions on health. He is also always focused on his popularity. Today it’s at his all-time high (47%).

If it begins to fall, as it generally does for presidents once they are in office, and Trump perceives that unpopular health proposals threaten to drive his ratings lower, he could abandon unpopular health proposals that cut spending. But, this could create other political problems with members of Congress who want spending reductions to help pay for tax cuts.

Four big proposals matter the most and at least three of them will be unpopular once debate about them begins. They also will engender strong stakeholder opposition. These include imposing a Medicaid per capita cap with an unprecedented cut in federal Medicaid funding to states; significantly cutting federal matching funding for the Medicaid expansion, which will all but kill the expansion in the 41 states, including D.C.; imposing Medicaid work requirements nationwide; and not extending the Affordable Care Act’s (ACA) enhanced premium subsidies, which will drive up out of pocket premium costs by more than 75% for enrollees.

Of the four, the public reaction to work requirements is the most uncertain. Work requirements are an indirect way to cut the Medicaid rolls and do not lead to work, but that requires a lot of explanation that does not come through in “he said, she said” news coverage, and the idea of promoting “work” is popular, especially with Republicans who view Medicaid as a form of welfare.

The per capita cap, expansion cut, and work requirements will likely be wrapped up in a reconciliation bill or bills to help pay for tax cuts. However, news media coverage tends to look at each proposal one at a time, making them more understandable for readers and viewers but missing the larger overall impact they have together on the program, the federal role in health and on people. The ACA premium subsidies will expire without action to extend them, and almost certainly will be treated as a separate matter and a separate news story. The subsidies, however, are connected to the Medicaid cuts because the only real shot at coverage people losing Medicaid will have will be in the marketplaces, and they will no longer be as affordable for former Medicaid beneficiaries if the subsidies lapse. People below poverty now covered under the Medicaid expansion won’t be eligible for ACA subsidies at all.

Whatever ideological appeal the proposals have to conservatives, they will reduce or eliminate coverage for millions of Trump voters who are expecting the new administration to make their lives better. They will also bring immediate pushback from hospitals and nursing homes that rely on Medicaid revenues and from the Medicaid managed care industry (over half of Medicaid dollars flow to that industry). Governors will react strongly to the cuts, and if implementation is pushed back to cushion the blow for currently serving Republican governors, it means running up the deficit further to pay for tax cuts, angering deficit hawks.

There is a time-honored pattern here: what is ideologically appealing initially to Republicans about reducing the size and scope of Medicaid almost always becomes a much more prosaic debate in the end about federal budget politics, money for states and the health care industry, and taking benefits away from people.

It’s an open question how President Trump will react to big Medicaid cuts and changes. He could support them all, just some and not others, or even reject them all. What can be said is that Trump’s silence on Medicaid also preserves his flexibility to respond in almost any fashion once he sees how the debate is shaping up and how his overall popularity is faring. There will, however, be no public debate unless media coverage is commensurate with the importance of these proposals. It’s early, but so far it has not been.

View all of Drew’s Beyond the Data Columns

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