Name: Medicaid Is Huge. Here’s Why, and What Trump’s Cutting.
Uploaded: 2025-07-17T04:00:00Z
Duration: 5 min 1 s
Description: Medicaid began as a welfare program, but 60 years later it covers one in five Americans. WSJ explains how it got so big, and how the “Big Beautiful Bill” will change it.

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Medicaid began as a welfare program, but 60 years later it covers one in five Americans. WSJ explains how it got so big, and how the “Big Beautiful Bill” will change it. Photo: Getty Images/Bloomberg

https://m.wsj.net/video/20250716/446d8f5c-af38-4635-8e87-d0ab73adde78/1/hls/manifest-hd-wifi.m3u8

Medicaid began as a welfare program, but 60 years later it covers one in five Americans. WSJ explains how it got so big, and how the “Big Beautiful Bill” will change it.

Medicaid Is Huge. Here’s Why, and What Trump’s Cutting.

Narrator: Medicaid is huge. It covers nearly a quarter of Americans and costs more than $800 billion huge. But this chart is total spending. Here's what the federal government share has been, and it's projected to grow even more in the next decade. But the Republicans' "Big Beautiful Bill" is estimated to cut the spending to here, largely by lowering the number of people covered. Medicaid really started small, so how did it get so big and who's going to be affected? A quick history lesson. In 1942, Congress gave president FDR the power to freeze wages to fight inflation, which he did. So in order to compete for employees, businesses offered benefits like this new thing called health insurance, which only 9% of Americans had. The IRS then said that employees didn't have to pay taxes on their insurance premiums, and the Supreme Court ruled that unions could bargain for insurance. By 1950, more than half of Americans had private health insurance. This is what set up the US as one of the only developed countries without some form of universal coverage. And because the system ties coverage to a job and those old enough to be working, it creates gaps of people who are uninsured.

There's a buildup of tension over who's left out, and suddenly we end up with a new system that doesn't cover everyone, but adds the elderly and adds people in poverty.

Narrator: He's talking about Medicare, which was created for anyone older than 65, regardless of income. And Medicaid, created at the same time, but at first only for those already on state welfare.

It was an afterthought. It was not seen as a program that was designed to survive and grow.

Narrator: And while Medicare is funded through payroll taxes, just like social security, Medicaid is federal assistance to states running their own programs.

The funding logic of Medicaid has made it both contentious, unstable, but also explains its expansion. Every state was able to sign on and to negotiate issues like coverage. That flexibility also allowed states to, in some ways, like tailor the system to their population. As people often say, if you've seen one Medicaid program, you've seen one Medicaid program.

Narrator: Over the years, as states would expand their eligibility, Congress would often follow suit, eventually covering the disabled, infants, and pregnant women in poverty, children in poverty, eventually children not in poverty, and even single working adults with lower incomes under the Affordable Care Act.

These were incremental changes to try to leverage the program to help fill in the gaps for individuals that had no other access to insurance coverage.

At any given moment, you have people saying, I know, let's just change eligibility because people need coverage.

Narrator: So now this is what healthcare coverage looks like in real numbers in the US. Most working age adults still get their insurance through their employer, some through public programs like those in the military, many who make just over the poverty line or are disabled are on Medicaid, as are a lot of children, even if their parents don't qualify. Nearly everyone 65 and older has Medicare and most also have an additional type of coverage. Many people buy health insurance directly on their own. Most use the healthcare.gov marketplace created by the Affordable Care Act for those that make too much for Medicaid, but can't access or afford employer coverage. Nearly all of them receive tax credits to make it affordable.

I think it's fair to say it's all patchwork.

In the last few years, we've had record low on numbers of people without health insurance. Obviously with the changes in the bill, there's anticipation that a number of uninsured will go up.

Narrator: It's estimated 8.7 million of these people would become uninsured because of work requirements and administrative barriers.

Imposing work requirements doesn't actually lead to additional employment, but does create these barriers to being, for people being able to maintain their coverage. So more individuals wind up without health insurance coverage,

Narrator: And because the tax credits for the marketplace are not being extended, an estimated 4.2 million could lose coverage, because it would simply cost too much, and losing that coverage doesn't mean they can just join their employer plan. Less than half of those with low incomes have access to insurance through their jobs. Even fewer part-time workers.

Robin: There just aren't a lot of other options.

Narrator: Medicaid has grown so large because it patches the gaps of those left out of this employer coverage based system, but now for the first time, that gap is going to widen.

Some days the high-speed news cycle can bring more questions than answers. WSJ’s news explainers break down the day's biggest stories into bite-size pieces to help you make sense of the news.

Medicaid Is Huge. Here’s Why, and What Trump’s Cutting.

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