Hear ye, hear ye, citizens of the land—the “One Big, Beautiful Bill” will bring about the political demise of Donald Trump.
Or at least, that’s what Democrats seem focused on telling us—that this massive reconciliation bill, currently ping-ponging back and forth between the House and Senate, is bad politics. It steals from the poor to give to the rich. It antagonizes a base which will soon come to recognize that MAGA does not represent its economic interests. And voters will assuredly make Trump and the Republican Party pay the ultimate political price for breaking their campaign promises, bringing about a 2026 blue wave of Kanagawa proportions. Sure, that could prove to be right. The bill has little, indeed almost nothing, to recommend itself on political grounds, for precisely the reasons that critics say—it hurts working Americans, undermines the already disintegrating integrity of our fiscal system, and benefits the super-rich (whose votes still only count for one) far more than any other constituency. But Democrats have become the party of wishful prognosticators, not spirited resisters, and we should presume they are incorrect about this prediction of Donald Trump’s doom at the hands of his big, beautiful bill—throughout Trump’s political career, they have never once successfully predicted lasting political consequences for his actions.
But this article is not about the politics of the bill or its consequences for the midterm elections. It is about the most politically and electorally insignificant thing imaginable these days: policy. More than anything else, the “One Big, Beautiful Bill” is quite possibly the dumbest piece of major fiscal policy proposed in American history. Sure, it is cynical for Republicans to throw a handful of populist measures like “no tax on tips” and “no tax on overtime” into the most regressive bill in forty years (by the way, those policies would affect so few people as to have a borderline negligible impact on after-tax income for lower tax brackets). Yes, it is definitely immoral for the Republican Party to sacrifice the welfare of much of its underinsured base for marginal increases in the satisfaction of its donor class. It is Orwellian of them to use magical mafia-bookkeeping logic to pretend that extending $3.8 trillion of tax cuts will cost the country $0 (yes, they are actually claiming this). The “One Big, Beautiful Bill” is all of these things. But above all, it is just stupid—its numbers don’t add up, its policies conflict with each other, and its aims are short-sighted. It’s a rush job—a half-baked college essay being turned in at 11:59 to a “professor” who is definitely not going to even read it.
Because it is such a massive bill, only the most die-hard of Lemur policy wonks would be likely to read through an explainer on why so many of the bill’s “beautiful” measures are so hideously ignorant (perhaps in installments?). So let’s focus on just one issue, perhaps the biggest, most disastrous, and most controversial measure in the entire bill: its introduction of work requirements for Medicaid enrollment.
What is Medicaid?
Medicaid is the United States’ largely federally funded (costs are shared with states) health insurance program for low-income Americans. Over 71 million Americans are currently enrolled in Medicaid, including over 80% of children living below the poverty line. Medicaid provides comprehensive health insurance for those who cannot afford private coverage, or whose employers do not offer it. It funds essential, life-saving services for millions of Americans, including single mothers, the disabled, the homeless, and other vulnerable populations.
Medicaid is not the dole. Most Americans on Medicaid work, full stop. Others study, volunteer, take care of family members, or are otherwise prevented from paying for private insurance plans because of physical disability. Because Medicaid is designed to serve these populations, on the premise that they are not able to insure themselves otherwise, the program has not historically required proof of employment for enrollment, and so includes many unemployed, underemployed, and not currently working Americans (again, many of whom are prevented from having full-time jobs by disability or obligations, such as the need to raise young children or take care of ill family members).
The program is wildly popular, which, again, is part of why it is so bizarre that Republicans are trying so fervently to dismantle it as part of their effort to extend tax cuts, largely for the super-wealthy (as a sidebar, an analysis of the distributional benefits of the tax cuts by the Yale Budget Lab can be found here—the top tax bracket will see by far the greatest increase in after-tax income from these cuts).
Why are the work requirements such bad policy?
The “One Big, Beautiful Bill” is very likely to pass with some version of the Medicaid work requirement measure included (the reconciliation process requires that the same version of the bill be approved by both the House and the Senate). This will be an unconscionable policy decision that will have grave moral and material consequences for millions of Americans for decades. But beyond these moral concerns—which seem to carry little sway with lawmakers, who, it must be assumed, either fear political retribution or simply do not care—the measure is simply (like so much else in this gargantuan, Frankenstein’s monster of an omnibus bill) a very, very dumb policy.
So let’s set aside the moral arguments and look at the bottom line. What evidence do we have that instituting work requirements for Medicaid enrollment will help reduce fraud and administrative inefficiencies in Medicaid, the goals Republican lawmakers allege they are focused on achieving? What evidence do we have that it will boost employment or encourage able-bodied formerly eligible recipients to get jobs, another GOP fall-back claim?
Only two states have implemented work requirement programs which have lasted long enough to result in coverage loss for state residents (other programs have stalled or been struck down by court rulings). First, there’s Arkansas. In 2018, Arkansas implemented a work requirement for Medicaid—conditioning eligibility on employment or participation in “other qualifying activities” such as volunteering or job search, for 80 hours a week. The results, according to multiple studies, do not exactly inspire confidence. The work requirement cut 18,000 Medicaid enrollees, while neither dramatically reducing state spending nor boosting employment. If we assume that the state of Arkansas had similar motivations to the federal government in pursuing the policy in the first place—balancing the budget and piloting a measure to motivate employment—the failure of the program should indicate that we should have no expectation that it would succeed when scaled up to the federal level (while the Arkansas program was halted by a federal court ruling in 2019, there is also no reason to assume that its premature suspension is sufficiently explanatory for its shortcomings).
The Arkansas example is the best empirical indication we have of how these work requirements might play out nationally, and studies of its failure sit atop a body of growing research which flatly disproves the hypothesis that conditioning eligibility for enrollment in public health insurance plans on an arbitrary employment threshold is likely to have a positive impact on the economy or provide health insurance “only for those need it.” The insurance disenrollment impact of the policy is astronomical—the Arkansas work requirements contributed to skyrocketing uninsurance levels for poor and middle-class 30-49 year olds and, because the state’s expansion Medicaid system also supported Arkansans trying to buy supplementary private health insurance, the cuts also led to a decrease in private health insurance coverage. The “extreme levels of red tape” imposed by the program and its monthly reporting (which is replicated in the “One Big, Beautiful Bill”) add even more administrative burdens to an already complex system.
The Arkansas example also provides no compelling economic argument that the benefits of this policy would outweigh the costs. A study even concluded that the Arkansas work requirements did not have any impact on employment: “we did not observe any changes in employment associated with Arkansas’s work requirements. The policy’s effect on employment among the affected age group was negative, small, and statistically insignificant. We also found no significant effects on other measures of work, such as hours worked or on employer-based coverage” (in fact, earlier studies have linked Medicaid expansion—not cuts—with positive effects on the labor market. See Craig Garthwaite, Tal Gross, Matthew J. Notowidigdo, Public Health Insurance, Labor Supply, and Employment Lock , The Quarterly Journal of Economics, Volume 129, Issue 2, May 2014, Pages 653–696, https://doi.org/10.1093/qje/qju005).
The reason that work requirements for Medicaid do not boost employment is because of the simple fact that is that “nearly all Medicaid enrollees are already working, looking for a job, enrolled in school, caring for a family member, or have health conditions or disabilities that prevent them from working.” These Medicaid enrollees include those who are underemployed by necessity—people who could not meet an 80-hour-a-month work threshold because they have to care for ill or disabled family members, for example. When Republicans say that disenrolling currently non-working or unemployed people from Medicaid will “motivate” them to get jobs, they are either disingenuous or uninformed—the notion that work requirements (not just for health insurance, but also for SNAP and other programs) boost employment is a kind of magical thinking which could not be conscionably published in any reputable economics textbook. And after the nightmarish months of peak DOGE and its slash-and-burn approach to spending, Republicans have lost the benefit of the doubt when they say they are going after “waste, fraud, and abuse.” Medicaid fraud is a bogeyman, just like Elon Musk’s Social Security vampires: it is simply not a major administrative inefficiency in our fiscal system the way that, say, an underfunded and under-resourced IRS is.
Further proof of the administrative inefficiency of Medicaid work requirements comes from the recent Georgia Pathways program, an ongoing pilot work-requirements program in the Peach State which, like the one in Arkansas, has failed to produce desirable results. An investigative report by ProPublica revealed that only 6,500 Georgians have successfully enrolled in the program after 18 months, including fewer than 10 people in many of the state’s rural counties, far lower than architects of the the policy claimed it would. According to a study by the Georgia Budget Policy Institute (GBPI), a nonpartisan think tank, “a cumbersome enrollment process and restrictive eligibility criteria appeared to contribute to the program’s lack of success in the first year.” Through the Project 2025 pipeline, this failing pilot program, which required the same kind of confusing monthly paperwork which also prevented thousands from even finishing their applications in Arkansas—has provided a blueprint for the work requirements introduced in the “One Big, Beautiful Bill.”
The failure of Georgia Pathways proves that Medicaid work requirements place undue administrative burdens on enrollees, measures that actually increase the bureaucratic inefficiencies in our healthcare system. If the goal of instituting the work requirements is to try to reduce administrative costs in healthcare, the policy will backfire. In fact, the GBPI concluded that “spending on upgrades to Georgia’s online eligibility and enrollment system represents the largest proportion of total program costs and was almost five times higher than spending on healthcare benefits for enrollees.”
So in addition to being morally unconscionable, the Medicaid cuts in the “One Big, Beautiful Bill” are also just bad policy—they burden our healthcare system with unnecessary administrative costs and yield no statistically significant benefits to employment or insurance in return. Unfortunately, given the velocity with which this omnibus reconciliation bill has been hurtled between chambers of Congress (President Trump imposed an artificial deadline of July 4 for passage), it is not surprising that the quality of its contents is so low. Republicans have deliberately taken this warp-speed approach in order to prevent their political opponents from galvanizing public outrage against the bill’s most unpopular measures, including the Medicaid and SNAP cuts. Republicans are also in the business of preventing members of their own party from facing pressure from constituents who wish to see their healthcare protected. Many congresspeople have scarcely had time to skim the bill, let alone read it, and are unfamiliar with many of its measures. This get-away-with-murder strategy is succeeding—only one Republican Senator, Thom Tillis of North Carolina, has been willing to come out in opposition to the bill on the grounds of its cuts to Medicaid, and he had to sacrifice his political career in order to do so.
The result of this time pressure, combined with the loyalty-test culture of the Republican Party, is quite possibly the most incoherent, unproductive, and irresponsible piece of major fiscal policy ever proposed in the United States. The bill will raise the federal deficit by $4 trillion (and $5.5 trillion if made permanent), including interest, according to the nonpartisan Committee for a Responsible Federal Budget (for a country that is already paying more per year on national debt interest payments than it is on defense). Other figures are arguably even more alarming: some fiscal hawks and deficit doomsayers like to focus more on the debt-to-GDP ratio as opposed to the gross value of our debt. That figure is currently 1:1—if this bill is passed, it would rise to 1.3:1, which may not sound like much, but is really astounding when you think about it. That number means our debt would be worth 130% our gross domestic product, a reality which could cripple this country’s economic future.
Because of that massive deficit explosion, the Medicaid work requirements policy become frustratingly, unbelievably pointless. Even getting rid of Medicaid entirely would not pay for the unimaginable increase in our deficit that this same bill imposes, and that is what makes the bill so self-destructive and defeatist. In exchange for painful and deadly cuts to health insurance for millions of Americans, we get…basically nothing. The cuts will barely pay for any of the deficit increase, and their impact will only wane with time as yearly interest payments on our debt rise. Based on current projections of disenrollment, the work requirements will “save” the government the fiscally paltry sum of $109 billion over the next decade, around 4% of what the tax cuts will take from the government’s budget. The number is so small that it won’t even pay for the borrowing this bill sets aside for increased funding of Homeland Security.
And as I demonstrated earlier, the supposed benefits of this policy have proven time and again, in both theoretical economic research and empirially tested real-life examples, to be phantoms. Every argument for the economic benefits of the Medicaid work requirements relies on false premises and imaginary conclusions—it won’t boost employment, it won’t resolve fraud, and it will actually increase bureaucratic inefficiency within the Department of Health and Human Services.
If Republicans are interested in increasing employment, perhaps they should consult the history of policies which have actually succeeded in improving labor supply, like federal infrastructure spending, tax credits for construction, and, well, not gutting higher education. If they are interested in reducing fraud, perhaps they should focus on reforming the government’s administrative capacity to track and prevent misuse of its funds, meaning resourcing the outgunned IRS, among other agencies. If they are interested in genuinely reforming Medicaid to facilitate pathways back to employment for its recipients, they should embed job-training and child-care initiatives within the system, a reform which might actually be very helpful.
But even a focus on a program like that belies the real problems here. It is not economically sound for Republicans to pretend that employment is a major challenge faced by our economy—as of May, the unemployment rate in the U.S. sits at a health, efficient, and reasonable 4.2%. Our economy is fine (at least in this way); our healthcare system is not. The primary challenge facing the able-bodied and work-age Medicaid population in this country is not finding good and lasting jobs; it is finding good and lasting health insurance.
