For the sake of argument, let’s assume that the most dire Democratic prognostications over Medicaid reforms in President Donald Trump’s One Big Beautiful Bill Act come true:

By 2034, nearly 12 million low-income Americans are “kicked off” their Medicaid coverage. The elderly and disabled face mounting medical debt. Rural hospitals, starved of Medicaid funds, shutter en masse. Life expectancy plummets. Skyrocketing inequality fuels social unrest.

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It is a daunting scenario, no doubt. But is it necessarily worse than the long-term consequences of allowing Medicaid to continue sprawling with no end in sight?

Opponents of the bill, including Democrats, their media allies, and many religious leaders, seem to think so. They treat their position as the moral default, sidestepping the coming fiscal wreck caused by Medicaid’s rapidly rising annual price tag.

On Thursday, Archbishop Timothy P. Broglio, president of the U.S. Conference of Catholic Bishops, or USCCB, condemned the bill’s “unconscionable cuts to healthcare and food assistance,” warning that “people will lose access to healthcare and struggle to buy groceries.” 

Yet, like many critics, Broglio fails to acknowledge the dire fiscal realities or offer alternatives for reforming a program that is bankrupting America. This silence implies that maintaining and expanding Medicaid is, in their view, the only morally acceptable path. For Broglio and his fellow critics, the long-term well-being of the nation’s poor can only be secured one way — the Democratic Party’s way.

Means and ends

Too often in our political discourse, divergence from liberal orthodoxy — in this case, over the best means for maintaining a viable healthcare safety net for the poorest Americans — is met with moral condemnation, and alternative approaches are taken as evidence of indifference if not outright malice. 

The same dynamic was obtained during the racial justice fervor of 2020. Suddenly, prevailing sentiment embraced only one very particular way of combating racism: the “anti-racism” model proposed by Ibram X. Kendi and other radical academics. Treating people equally regardless of race renders one insufficiently “anti-racist” and thus racist. Only Kendi’s doctrines — such as enforcing equitable racial outcomes through government power — gained acceptance as legitimate means of combating racism.

Similarly, large-scale, government-led green initiatives stand as the sole morally acceptable means to planetary stewardship. Broglio’s statement went on to lament the law’s cuts to clean energy tax credits, which he described as “programs that protect God’s creation,” as if they are both morally incontestable and effective. Meanwhile, conservative alternatives, such as unleashing technological innovation stifled by overregulation and prioritizing economic growth over burdensome taxation (as only wealthier societies can afford cleaner technologies), are dismissed ipso facto as morally inferior. One must either commit to wasteful and ineffective environmental policies or be branded as indifferent to the planet’s future.

Medicaid reforms

Critics of the Medicaid reforms in the One Big Beautiful Bill Act appear convinced of reformers’ indifference to the poor and that their sole aim is to deliver “tax breaks to their billionaire friends.” More than simplistic political spin — indeed, for every billionaire who backed President Donald Trump in the previous election, two backed former Vice President Kamala Harris — these criticisms imply that expanding the welfare state is the only morally acceptable policy.

But allowing Medicaid to sprawl at its current rate will almost certainly lead to a severe economic crisis that will disproportionately harm low-income people. 

Originally designed as a safety net for those unable to afford healthcare, Medicaid has become the nation’s largest single source of healthcare funding, covering nearly a quarter of the population. Its explosive growth under the 2010 Affordable Care Act added 20 million to the rolls by expanding coverage to most nonelderly adults with incomes up to 38% above the federal poverty level. The Biden administration further boosted enrollment by reversing work requirements and extending the Continuous Enrollment Provision during the COVID-19 pandemic.

Federal spending on the program has since surged by approximately 60%, costing taxpayers $890 billion in fiscal 2023. Projections show annual Medicaid spending will reach $1 trillion within a decade. The explosion in means-tested welfare programs, particularly Medicaid, is the main driver of the national debt, which currently sits at approximately $36 trillion.

At some point, these levels of sustained debt will spark an economic crisis. Projections on when the “debt bomb” will explode differ — the Penn Wharton Budget Model estimates the U.S. debt held by the public cannot exceed approximately 200% of GDP without triggering a crisis, while the Manhattan Institute projects that interest costs could consume nearly all federal taxes within three decades. All agree that its effects would disproportionately punish the poor. 

Severe fiscal crises driven by high government debt often trigger austerity measures, forcing deep cuts in social programs. Medicaid, in such a scenario, would likely suffer reductions far exceeding those in the One Big Beautiful Bill Act.

Additionally, such a fiscal crisis would severely damage the economy, inflicting disproportionate harm on the most vulnerable. Inflation, a common consequence of debt-driven crises, would be a primary culprit. Increased costs would force households to swallow a larger share of their budget in necessities such as food and energy. Fixed incomes, common among retirees or the disabled, would be especially vulnerable to an erosion in purchasing power.

It is far from a certainty that reforms to Medicaid in the new law will inflict greater suffering than a debt-driven economic crisis — and certainly not in the long run. Will more suffering come from the implementation of work requirements or increased eligibility checks, or increased overall poverty from a debt bomb? For Broglio and his fellow critics, this question seems not to enter into their moral judgments. 

The truth about the One Big Beautiful Bill Act

There is ample reason to suspect that the doomsday scenarios outlined by Democratic critics of the law are exaggerated for political effect — and that the discourse is heavily influenced by rhetoric designed to emotionally strong-arm opponents.

Indeed, no one is being “kicked off” Medicaid who doesn’t belong on the rolls in the first place. The law targets the ACA’s expansion of Medicaid to able-bodied adults above the poverty line. Requiring a 20-hour work week for recipients (except for the disabled, pregnant women, and those caring for children under 14), or 20 hours of volunteering or going to school, is hardly draconian. In fact, it’s far less stringent than the work requirements former President Bill Clinton signed into law in the 1990s. 

Even with the proposed cuts, the bill’s estimated $1 trillion in savings over the next decade means Medicaid’s annual spending will still increase, just at a slower rate. Far from being “gutted,” this law only gives the program a trim.

The law also targets the rampant waste, fraud, and abuse in the program that costs taxpayers billions each year. A recent Paragon Institute study found that an estimated $1.1 trillion in improper Medicaid payments occurred over the past decade. It also showed that states have incorrectly classified at least 5 million people as expansion enrollees under Obamacare’s expansion. This error costs federal taxpayers approximately $30 billion each year.

Cleaning up this mess will strengthen the program for the poor and ensure that it exists well into the future. Ignoring it, or, as Democrats and Broglio would prefer, expanding it even further risks collapsing the entire system. 

The 2024 Democratic platform plank on Medicaid underscores the party’s dangerous fiscal irresponsibility: 

“As Democrats, we support Medicaid expansion, encouraging states to provide health coverage to low-income Americans on the federal government’s tab,” it reads. “The Biden Administration has helped over a million people in four states to enroll; and we’ll keep pushing Congress to further expand Medicaid-like coverage to the 2.8 million uninsured low-income adults who live in states where Republicans still refuse the help.”

THE BIG BEAUTIFUL BILL IS A HUGE REPUBLICAN ACHIEVEMENT

Who exactly has the best interests of the poor in mind here? The party willing to reform and strengthen a broken system designed to benefit the poor, or the party willing to allow it to spiral out of control and eventually collapse? 

One of these options speaks to a profound moral failure. And it isn’t the one Broglio and his fellow critics think.