If Republicans are serious about making a dent in the federal budget while improving the health care system, Medicaid would be among the first places to start.

A little over a decade ago, Obamacare dramatically expanded Medicaid eligibility by raising the income thresholds and allowing more able-bodied individuals into the program. After Republicans balked at the chance to repeal it during the first Trump administration, enrollment swelled further during the pandemic, with the number of people benefiting from the expansion eclipsing 20 million (representing nearly one out of every four of the program’s 83 million enrollees). In 2013, the year prior to the expansion, the program cost the federal government $265 billion; in 2017, during the failed repeal effort, the cost was $375 billion; last year, that number rose to a staggering $617 billion (states added several hundred billion more). 

With unified control of government and a reconciliation bill in the works that would allow Republicans to pass legislation with a simple majority, they have another opportunity to deliver reforms that they avoided eight years ago. 

While there are plenty of ideas out there – reducing the number of able-bodied adults on the program, adding work requirements, providing per capita payments to states that grow only at a sustainable rate, and more – the hangup has always been Republicans’ fear of public opinion. But a new survey, conducted on behalf of the Paragon Health Institute (run by Brian Blase, former Republican policy staffer and health care advisor in the first Trump administration), points to an opening for Republicans on the issue. 

To be sure, the results of the Paragon poll do demonstrate pitfalls for Republicans. A majority of 53 percent said that “Congress should leave federal health care programs alone and not use them to help fund the tax cut renewal” compared with 47 percent who said that federal health care programs should be on the table. These numbers could end up a lot worse for Republicans after months of Democratic messaging that “Republicans are slashing health care for the poor to fund tax cuts for the rich.”

But the survey also found that when framed differently, the numbers become more positive for the pro-reform side. Support rises to 66 percent favoring reform when stated as: “Congress needs to take a hard look at all federal health care programs to ensure taxpayer dollars are spent wisely. Weeding out waste, fraud, and abuse would save billions and help safeguard these vital programs, so they are available for those who need them – now and in the future.”

An even higher number – 84 percent – said they supported allowing states to add work requirements to Medicaid for able-bodied adults. They were also more likely to oppose the Obamacare Medicaid expansion when told that the relatively more generous funding for able-bodied adult beneficiaries has made it harder for traditional enrollees (such as pregnant women, children, and the disabled) to access care. This was the subject of a recent Paragon paper calling for financing reform. 

As Republicans look for ways to reduce spending, Medicaid should be high on their list.