America is facing a Medicaid crisis — and not because the program is too small or too stingy. The real problem isn’t funding. It’s priorities. It’s accountability. And it’s whether Medicaid as we know it can survive the next decade.

The House-passed reconciliation bill, the one “big, beautiful bill,” takes long-overdue steps to protect Medicaid for the people it was always meant to serve. It doesn’t gut the program. It saves it.

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Let’s be clear about what this bill does and what it doesn’t. It does not cut benefits for anyone who qualifies. It does not reduce access for seniors, people with disabilities, or low-income children. What it does is protect the program from being overwhelmed by fraud, abuse, and unchecked expansion to people who were never meant to be covered. If we want Medicaid to survive, we must return it to its original mission: serving the truly vulnerable.

This debate reveals a deeper divide. Both parties say they want to help people. But only one has a plan that balances compassion with common sense.

Democrats often pursue policies that sound generous but ignore long-term consequences. Their approach treats Medicaid like an unlimited entitlement — open to anyone, regardless of work status, legal status, or even eligibility.

That approach isn’t sustainable. In too many cases, those who need help most are pushed to the back of the line while the system grows more bloated, inefficient, and expensive.

The reconciliation bill makes three critical reforms to protect the integrity of Medicaid, ensure fairness for taxpayers, and restore the program’s focus on the people it was created to serve.

First, work requirements. This reform applies only to able-bodied adults without dependents. It simply says: If you want taxpayer-funded health care, you should contribute 20 hours a week through work, job training, or community service.

That’s not cruelty; it’s respect. Respect for the people who pay into the system. Respect for those who truly can’t work and need our help. And respect for those who can work but may have lost the structure and support to do so.

Because work isn’t just about a paycheck. It gives us something even more valuable: purpose. It fosters pride, confidence, routine, and connection. A healthy society doesn’t just hand out benefits; it helps people stand on their own. And that starts with the dignity of work.

Second, stopping fraud. Medicaid has, for too long, operated on the honor system. During the COVID-19 emergency, states were barred from removing ineligible recipients. As a result, millions stayed on the rolls even after they no longer qualified. That’s not just wasteful; it’s unjust.

Federal auditors found more than $80 billion in improper Medicaid payments just last year. That’s more than eight times Iowa’s state budget. Every dollar spent improperly is a dollar stolen from someone who actually qualifies — someone battling cancer, living with a disability, or trying to make ends meet on a fixed income.

The reconciliation bill gives states the authority and obligation to verify eligibility, clean up their rolls, and crack down on abuse. That’s not punitive; it’s protective. It safeguards the people who play by the rules. It restores public confidence in the system. And it ensures that Medicaid remains strong for those who truly depend on it.

Third, ending coverage for illegal immigrants. Medicaid was never meant to serve as a backdoor incentive for unlawful immigration. But that’s what it’s becoming under the current policy.

That is neither humane nor sustainable. It drains state budgets and delays care for citizens and legal residents. Every dollar spent on someone here unlawfully is a dollar that could have gone to a child with disabilities, a senior in crisis, or a low-income parent struggling to care for his or her family.

This isn’t about politics; it’s about priorities. A program designed to serve America’s most vulnerable must actually serve America’s most vulnerable.

These reforms aren’t radical. They’re reasonable. They reflect a clear truth: Compassion without limits is not kindness; it’s chaos.

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Here’s the defining difference. Democrats want applause for generosity they don’t have to pay for. Republicans want results that last. We believe that safety-net programs should be strong but focused. That government assistance should uplift, not trap, those it serves. And that real compassion means building a system that can endure.

Congress has a choice. It can patch over the problems in Medicaid with more borrowed money and political slogans. Or it can step up, be honest about what’s broken, and fix it. The reconciliation bill does the latter. It protects the program. It respects the taxpayer. And it restores Medicaid’s promise: to serve the truly vulnerable today, tomorrow, and for generations to come.

Kim Reynolds is the 43rd governor of Iowa.