In the fabric of American life, Medicaid is a silent thread holding together the health and well-being of over 80 million people. From low-income families and children to people with disabilities and seniors in long-term care, Medicaid provides essential medical services to those for whom access to healthcare is not a given but a daily worry. Yet, despite its indispensable role, Medicaid now faces some of the most severe threats in its nearly 60-year history.

The threat is not abstract. In May 2025, House Republicans passed the so-called “One Big Beautiful Bill Act,” an ambitious legislative package championed by President Donald Trump and aggressively supported by Speaker Mike Johnson. Buried within this bill are drastic cuts to Medicaid that could lead to millions of Americans losing their health coverage, particularly due to newly proposed work requirements and eligibility restrictions. Though marketed as a push toward fiscal responsibility, the reality is far more dire for those at risk of being disenfranchised from lifesaving care.

I will explore the origins of Medicaid and its evolution, unpack the specifics of the proposed legislative changes, examine their human and economic consequences, and spotlight Iowa—a state that stands as both a cautionary tale and a call to action. Drawing from real stories, legal precedent, and public policy research, we will illustrate how this issue transcends politics. It is a moral reckoning with what kind of society we wish to be.

THE ROOTS AND EXPANSION OF MEDICAID: A PUBLIC PROMISE

Medicaid was established in 1965 under the Social Security Amendments signed by President Lyndon B. Johnson, during the height of the “Great Society” era. While Medicare provided health coverage to the elderly, Medicaid was created to extend care to low-income individuals and families, including those receiving cash assistance. Over time, eligibility expanded to include pregnant women, children, and persons with disabilities—even before the major reforms of the 2010 Affordable Care Act (ACA).

The ACA marked a watershed moment for Medicaid. Under its expansion provisions, states could opt to extend Medicaid eligibility to individuals earning up to 138% of the federal poverty level. By 2023, 39 states and the District of Columbia had done so, leading to significant reductions in the uninsured rate and improvements in healthcare outcomes, particularly in rural and underserved communities (Kaiser Family Foundation, 2023).

Yet Medicaid has always had political enemies. Critics, often on the political right, argue that the program encourages dependency and is fiscally unsustainable. These claims ignore the economic, medical, and social benefits the program delivers, and they have become the basis for repeated attempts to scale back the program. The most recent efforts, encapsulated in the “One Big Beautiful Bill Act,” represent the most significant threat in decades.

THE “ONE BIG BEAUTIFUL BILL ACT”: WHAT THE PROPOSED CUTS MEAN

The legislation passed by House Republicans includes a host of changes to Medicaid, all aimed at reducing federal spending. These changes include:

• Work Requirements: Able-bodied adults aged 19 to 64 would need to work, volunteer, or participate in job training for at least 80 hours per month to remain eligible. Non-compliance, regardless of intent or ability, would result in loss of coverage.
  
• Intensified Eligibility Checks: The bill mandates increased frequency and rigor in eligibility verification, which could lead to disenrollment due to administrative errors or technicalities, as occurred in Arkansas in 2018 (Sommers et al., 2020).
  
• Federal Funding Cuts: A shift in financial responsibility from federal to state governments could leave states with impossible choices—cut services, restrict eligibility, or ration care.
  
• Bans on Specific Services: Medicaid would be prohibited from covering certain treatments, including gender-affirming care for transgender individuals.
  

While Speaker Mike Johnson claims that “people will not lose their Medicaid unless they choose to do so,” the evidence tells a different story. Under similar work requirements in Arkansas, more than 18,000 people lost coverage—largely due to logistical barriers, not unwillingness to work (Sommers et al., 2019). Johnson’s framing is not just misleading; it is dangerous.

The Congressional Budget Office (2025) projects that this bill could lead to 15 million people losing healthcare coverage by 2034, including 10.3 million from Medicaid alone. The hardest-hit groups would be children, people with disabilities, the working poor, and rural Americans.

FACES BEHIND THE NUMBERS: STORIES THAT MATTER

To grasp the impact of these policies, we must move beyond statistics and center the lives of those most affected.

Maria, a single mother in Des Moines, juggles three part-time jobs, none of which offer health insurance. Her youngest son, eight-year-old Javier, has severe epilepsy and requires daily medication and regular neurologist visits. “We do not have savings. We do not have a backup plan,” Maria says. “If Medicaid goes away, I am not sure how I keep my son alive.” She works just under 80 hours per month due to childcare constraints. Under the proposed law, that shortfall could make her son collateral damage in a political war.

James, a disabled Army veteran in Council Bluffs, received spinal surgery and long-term physical therapy through Medicaid after delays at the VA. Though exempt from work requirements, James worries that changes in eligibility documentation could mistakenly strip him of benefits. “I served this country. I never thought I’d have to beg for the healthcare I was promised,” he says.

Lana, a 26-year-old transgender woman in Iowa City, uses Medicaid to access hormone replacement therapy and mental health counseling. The proposed ban on gender-affirming care would eliminate her only lifeline. “They want us to disappear,” she says. “They do not even want us to survive.”

These stories are not exceptions. They are examples of the real and devastating outcomes that can result from policies crafted without compassion or grounded understanding of lived experience.

THE ECONOMIC TRUTH: MEDICAID IS A LIFELINE, NOT A LEECH

Opponents of Medicaid often claim it is a drain on the economy, a bloated entitlement program that encourages idleness and fraud. However, this narrative does not withstand empirical scrutiny. In fact, Medicaid functions as a powerful economic stabilizer and community investment tool. Rather than weighing down the economy, Medicaid actively supports it in multiple ways.

• Job Creation and Local Economic Activity: Medicaid injects billions of dollars into state economies. A study by the Center on Budget and Policy Priorities (2020) found that states expanding Medicaid saw job growth in healthcare, retail, and construction sectors. Healthcare providers receiving Medicaid payments spend those dollars locally, creating a ripple effect across regional economies.
  
• Medical Debt Reduction: Research published by the National Bureau of Economic Research (2021) confirmed that Medicaid expansion led to significant reductions in personal medical debt, especially in low-income households. This freed up resources for housing, food, and education.
  
• Improved Public Health and Workforce Participation: By offering preventive care and chronic disease management, Medicaid enables people to remain productive, avoid emergency care, and live longer, healthier lives. A healthy population is not just a moral goal—it is an economic necessity.
  
• Support for Rural Hospitals: In many rural areas, Medicaid reimbursements keep the lights on. Without this revenue, many facilities would be forced to close, worsening healthcare deserts and increasing mortality from otherwise treatable conditions.
  

Fiscal responsibility should never come at the cost of human survival. Medicaid is not a giveaway—it is a guarantee that poverty should not equate to preventable death.

IOWA’S MEDICAID NIGHTMARE: A BLUEPRINT FOR FEDERAL DISASTER

Nowhere is the danger of reckless Medicaid policy more apparent than in Iowa, where a series of ill-conceived experiments with Medicaid privatization have already inflicted deep wounds on the healthcare system. If the federal government adopts similar cuts and requirements nationwide, the entire country could face what Iowa has already endured.

In 2016, under Republican Governor Terry Branstad, Iowa privatized its Medicaid system, handing administration over to for-profit managed care organizations (MCOs). The goal, according to proponents, was to save money and increase efficiency. In practice, it became a disaster:

• Widespread Provider Payment Delays: Healthcare providers across Iowa reported delayed or denied payments, leading many to stop accepting Medicaid altogether. As early as 2017, critical access hospitals, home health agencies, and mental health providers faced near-collapse due to unpaid claims (Iowa State Auditor, 2019).
  
• Disruptions in Patient Care: Patients experienced dropped services, difficulties accessing prescriptions, and long waits for specialist referrals. This disproportionately affected individuals with disabilities and chronic conditions.
  
• Lack of Accountability: MCOs cited proprietary protection to avoid disclosing financial details, limiting state oversight. One major MCO, AmeriHealth Caritas, abruptly exited the program in 2017, citing unsustainable losses—leaving patients and providers scrambling.
  
• Skyrocketing Administrative Costs: Rather than saving money, privatization led to increased costs associated with multiple layers of bureaucracy and profit incentives.
  

Despite these well-documented failures, Iowa’s leadership—including Governor Kim Reynolds and Senator Joni Ernst—continues to defend the model and resist a return to state-administered Medicaid. Their refusal to course-correct reflects an ideological rigidity disconnected from the lived experiences of Iowa families.

WHO DEPENDS ON MEDICAID IN IOWA?

As of 2025, approximately 850,000 Iowans are enrolled in Medicaid—nearly one in four residents. The demographics speak volumes:

• 300,000+ children rely on Medicaid for vaccinations, dental care, and pediatric services.
  
• 70,000+ elderly Iowans receive long-term care services that Medicare does not cover.
  
• Tens of thousands with disabilities use Medicaid to access home-based care, physical therapy, and assistive technology.
  
• Low-income adults, many of whom gained coverage through the state’s Medicaid expansion, rely on it for primary care and mental health services.
  

In rural counties such as Louisa, Monona, and Adams, Medicaid is not merely a safety net—it is the infrastructure of healthcare itself. These are places where private insurance is sparse, hospital closures are common, and broadband access is unreliable. When politicians in Washington, D.C. speak about cuts in the abstract, it is these communities that suffer the consequences in real time.

JONI ERNST: THE FACE OF CONTEMPT FOR THE VULNERABLE

Senator Joni Ernst (R-Iowa) has become one of the most visible proponents of Trump’s legislative agenda, including the proposed Medicaid cuts. Yet her tone-deafness on the issue was never more evident than during a now-infamous 2025 town hall exchange.

When a concerned constituent warned that cutting Medicaid and food stamps would lead to unnecessary deaths of her constituents, Ernst mockingly replied, “Well, we’re all going to die.” The comment, widely criticized for its callousness, was followed by a video in which she doubled down on her stance—filmed in a cemetery, no less—making sarcastic references to the “tooth fairy.” 

This moment was not just an isolated gaffe; it was emblematic of a larger worldview. To Ernst and her political allies, healthcare is not a right but a commodity. Poverty, disability, and hardship are not conditions to be met with compassion but with contempt.

Her alignment with House Speaker Mike Johnson, who insists that no one will lose Medicaid “unless they choose to,” underscores a shared political strategy: weaponize ignorance. They count on the public not understanding the bureaucratic traps these policies create—reporting requirements impossible for people without internet, proof-of-work forms that confuse even seasoned administrators, and renewal processes that can get derailed by a single typo.

It is governance by indifference, cloaked in the language of reform.

RESISTANCE IN MOTION: IOWANS STAND UP FOR THEIR HEALTHCARE

Even in the face of mounting political power and deep federal cuts, everyday Iowans are not standing down. From city centers like Des Moines and Cedar Rapids to rural towns like Ottumwa and Atlantic, communities are organizing to protect Medicaid and to push back against what they see as a betrayal of public trust.

Disability Rights Iowa, a prominent advocacy organization, has held forums educating people with disabilities on how to challenge denied claims and file complaints with the state’s ombudsman. They also help families navigate Medicaid redeterminations, which are expected to increase exponentially under the new verification requirements.

Planned Parenthood North Central States, which includes Iowa in its territory, has launched a Medicaid defense campaign focused on access to reproductive health services. Their advocacy has been particularly crucial in fighting gender-affirming care bans embedded in the legislation.

Iowans for Medicaid Access, a bipartisan grassroots coalition, has organized rallies, petitions, and voter registration drives. At a recent event outside Senator Ernst’s Davenport office, speakers included parents of disabled children, rural hospital workers, and a Vietnam veteran who nearly lost his cancer treatment due to delayed Medicaid paperwork. The crowd chanted, “Medicaid saves lives—hands off our care.”

Local healthcare providers are also adding their voices. In a joint statement, the University of Iowa Hospitals and Clinics, Broadlawns Medical Center, and several community health centers warned: “If the proposed federal cuts are enacted, the consequences will be immediate. Fewer staff. Fewer services. Worse outcomes. Higher mortality.”

These coordinated efforts represent more than policy disagreement. They are a community defense movement. And they are growing.

LEGAL PATHWAYS: CHALLENGING THE WORK REQUIREMENT NARRATIVE

The legal terrain is not entirely bleak. Courts have weighed in before—and ruled decisively—against similar attempts to restrict Medicaid access through bureaucratic and ideological means.

In 2020, a federal appeals court struck down the Trump administration’s approval of work requirements in Arkansas, concluding that the policy was “arbitrary and capricious” and violated the purpose of the Medicaid Act. The court emphasized that the statutory goal of Medicaid is to provide medical assistance, not to reduce enrollment by imposing unrelated conditions (Gresham v. Azar, 950 F.3d 93 [D.C. Cir. 2020]).

That same year, the U.S. Supreme Court was set to hear cases on the issue, but they were dismissed following the Biden administration’s withdrawal of the Trump-era waivers. However, legal scholars widely agree that work requirements undermine Medicaid’s core mission and would likely fail under judicial review again—if challenged correctly.

Additionally, the Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act offer powerful tools for challenging policies that disproportionately harm disabled individuals, even if unintentionally. Legal experts from the National Health Law Program and Disability Rights Education and Defense Fund are already preparing for litigation, particularly if states implement rules that effectively restrict coverage for people with mental illness or physical impairments under the guise of workforce participation.

THE SILENT DISASTER: MEDICAID AS A MORAL BATTLEGROUND

There is a reason why Medicaid does not receive the same impassioned defense in national discourse as Medicare or Social Security: stigma. Medicaid is often painted as a “welfare” program, and recipients as lazy or undeserving. This narrative, promoted for decades by politicians and media outlets alike, fuels apathy about proposed cuts. It lets lawmakers like Senator Joni Ernst get away with flippant cemetery jokes about death when constituents fear losing lifesaving care.

But Medicaid is not about handouts. It is about humanity. It is about a disabled adult being able to leave their house because a home health aide arrives every morning. It is about a child with asthma breathing easier because they can see a doctor. It is about a rural grandmother receiving chemotherapy without traveling three counties away. And yes—it is about economic justice, racial equity, and the right not to die for being poor.

To gut Medicaid is to gut the soul of our social contract.

PROTECTING MEDICAID IS PROTECTING DEMOCRACY

The “One Big Beautiful Bill Act” is not law yet. While it has passed the House, it faces a much tougher road in the Senate. Moderate Republicans and Democrats still hold enough leverage to reject or amend the legislation—if they hear from their constituents.

Here is what you can do now:

• Call Your Senators: Demand that they oppose any bill that includes Medicaid cuts or work requirements. Be specific. Share your story or the story of someone you know.
  
• Support Advocacy Groups: Donate to or volunteer with organizations like Families USA, the Center on Budget and Policy Priorities, Disability Rights Iowa, and the National Health Law Program.
  
• Share on Social Media: Break the silence. Use your platform to amplify Medicaid’s value and the harm these cuts will cause. Use hashtags like #ProtectMedicaid and #MedicaidMatters.
  
• Vote in 2026: Hold your representatives accountable. Make Medicaid an issue in local, state, and federal elections. Ask every candidate: Do you believe healthcare is a right?
  
• Educate Others: Host a town hall. Write an op-ed. Start a book club around healthcare equity. Policy shifts when minds shift—and minds shift when informed.
  

THE FUTURE IS IN OUR HANDS

Iowa is the canary in the coal mine. What happened when it privatized Medicaid—service cuts, confusion, deaths—could become the national norm if these federal policies go unchecked. The consequences of inaction will be counted not just in dollars, but in human lives.

Senator Joni Ernst may mock these concerns. Speaker Mike Johnson may gaslight the public into believing no one will lose coverage. But we know better.

Medicaid is not a partisan issue. It is a lifeline. It is dignity. And it is worth fighting for.

Do not wait until your neighbor is turned away from the ER. Do not wait until your grandparent loses in-home care. Do not wait until it is you.

Fight now.

Because healthcare is not a luxury.
It is a promise.
And we intend to keep it.

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SOURCES:

• Center on Budget and Policy Priorities. (2020). Medicaid Expansion Promotes Economic Mobility. https://www.cbpp.org/
  
• Kaiser Family Foundation. (2023). Medicaid Enrollment and Spending. https://www.kff.org/
  
• Gresham v. Azar, 950 F.3d 93 (D.C. Cir. 2020)
  
• National Bureau of Economic Research. (2021). Medical Debt in the U.S.
  
• Iowa State Auditor’s Office. (2019). Medicaid Privatization Report.