If we want to survive what’s coming next, we must stop viewing public policy through emotion and start seeing it through logic. Medicaid — one of the largest welfare programs in America — is finally being forced into financial reality. And while the new 2025 tax bill is controversial, it didn’t create the crisis. It simply exposed it.
This article is not a defense of the bill. It’s a call for clarity, discipline, and long-overdue accountability — especially for Black Americans who’ve been told to trust in promises that never delivered real outcomes. Politicians have played with our emotions long enough. It’s time to think, not feel.
Let’s be honest: most of what we were told about Medicaid under the Affordable Care Act (ACA) was emotional marketing dressed up as moral obligation. “Health care is a right.” “We’re expanding coverage for the vulnerable.” “No one should be left behind.” That all sounds good, but good intentions don’t cancel out bad economics. Under the ACA, the federal government initially covered 100% of the costs for newly eligible enrollees (able-bodied adults up to 138% of the federal poverty level), gradually declining to 90% by 2020 and beyond — still far more generous than traditional Medicaid matching rates.
States like New York and California not only took the deal, they ran wild with it — adding benefits, loosening eligibility, and building state-funded programs well beyond what was federally required. They covered able-bodied, childless adults with no disability. They funded care for undocumented immigrants using state-only money. They expanded optional services like dental, vision, and behavioral health. They paid inflated reimbursement rates to keep bloated, inefficient hospital systems from collapsing.
California is perhaps the clearest example of Medicaid expansion gone wrong. Its program, Medi-Cal, ballooned in size and cost to the point where the state could no longer sustain it. By 2024, the situation had become so dire that the federal government — using taxpayer dollars — had to intervene with a nearly $10 billion emergency bailout just to prevent Medi-Cal from defaulting on provider payments and cutting off care to vulnerable patients. Even then, state leaders tried to spin the crisis as a victory, despite the obvious fiscal collapse. You even had House Minority Leader Hakeem Jeffries defending the system, claiming: “Not a single undocumented immigrant gets a dime in federal taxpayer dollars for any part of comprehensive Medicaid coverage.” But what he didn’t mention was that California used state-only funds to expand coverage to undocumented individuals, adding costs to an already bloated and unsustainable program. That’s not sound policy — that’s failure held together by political theater.
Nationally, Medicaid enrollment ballooned from 56 million in 2013 to over 89 million by 2023, with nearly 1 in 4 Americans enrolled in the program — a cost trajectory that became politically unsustainable.
The 2025 tax reform bill — H.R. 1 — includes Medicaid changes that have shocked many, especially in high-cost states that built entire economies around federal funding. But let’s be clear: the bill didn’t slash Medicaid out of spite. It responded to years of irresponsible expansion and fiscal recklessness. It tightens eligibility enforcement to remove dead people, double-enrolled individuals, and ineligible recipients. It lowers federal reimbursement for administrative costs — from 50% to 25% by 2027. It imposes work requirements for able-bodied adults. It limits the state’s ability to game the system with provider taxes and inflated match requests. And it pauses unfunded mandates on long-term care staffing that many states couldn’t afford in the first place.
During the COVID Public Health Emergency, eligibility redeterminations were suspended, causing millions of ineligible individuals to remain on Medicaid rolls — including people who had gained employment or moved to employer-based plans. This artificially inflated Medicaid spending by billions and delayed necessary accountability.
These changes will hit hardest in states like California and New York — not because they were targeted, but because they overspent, overpromised, and built Medicaid systems on a foundation of borrowed time and unsustainable subsidies.
We must remember what Medicaid was originally designed for. Created in 1965, it was meant to support the disabled, elderly, pregnant women, and low-income families with children — not able-bodied adults without dependents. The ACA shifted that foundation.
Critics argue that the 2025 tax bill doesn’t address the federal deficit. But what they fail to acknowledge is that unchecked expansion and bloated enrollment—driven by state-level decisions—helped create that deficit in the first place. When states expanded beyond federal minimums, added non-mandated populations, and refused to clean their rolls, they inflated the costs without regard to long-term sustainability. Now state politicians — and even some federal ones — are crying wolf, ignoring that it was their very policies that created this mess in the first place. The bill may not solve the deficit overnight, but it shines a bright light on how we got here.
If we don’t understand how we got here, we’ll never understand how to get out. Some will say this sounds like support for the bill. It’s not. It’s support for facing reality. For choosing economic strategy over blind dependency. For demanding outcomes instead of clinging to slogans.
We are entering a new era — and Black America cannot afford to keep fighting for emotional wins when we’re losing in every measurable outcome. Medicaid is being restructured. Federal aid is being tightened. The age of unlimited handouts is closing. If we’re not prepared with a new mindset, we’ll be left holding empty promises while our communities collapse around us.
We need a survival strategy — and that begins with understanding policy, not reacting to it. If all politics are local, then we’ve been caught staring at Capitol Hill while the real problem was happening in our own state legislatures. It wasn’t Congress that ran up the Medicaid tab in New York — it was Albany. It wasn’t D.C. that mismanaged nursing home reimbursements — it was Sacramento. It wasn’t the federal government that built unsustainable hospital networks — it was local politicians who bet on a federal blank check that just got canceled.
Now, as Medicaid costs explode and federal dollars shrink, state budgets are breaking — and who do you think they’ll cut first? Seniors. Black communities. Low-income families. The very people the program was designed to protect.
This moment is not just a crisis — it’s a crossroads. With the Medicaid system being reshaped, Black Americans must pivot. Shift from dependency to production. Learn how policy changes affect business, housing, and healthcare economics. Focus on state-level action. Push local legislators to prioritize spending, transparency, and targeted relief for those most in need. Educate our people. Stop waiting for cable news or political parties to interpret policy for us. We need our own research, our own experts, our own strategic planning. Support outcome-based leadership. Elect people who deliver measurable results — not emotional speeches that lead nowhere.
If Black America is to survive the Medicaid pivot, we need to build health co-ops, community clinics, and independent support structures that reduce our dependence on state-run programs. It’s time to localize our solutions — because the federal safety net is fraying, and no politician is coming to fix it.
We have no more time for emotional politics. The safety net is being pulled back, and we can either collapse or adapt. This is about economic survival. If we understand how we got here, we can build strategies that move us beyond dependency and toward sovereignty. But if we keep reacting with feelings instead of planning with logic, we’ll keep losing — again and again.
References
U.S. Department of Health and Human Services (HHS).
Guidance on the End of the Continuous Enrollment Requirement and Unwinding Timeline.
https://www.hhs.gov/about/news/2023/01/05/end-continuous-enrollment-medicaid-guidance.html
Centers for Medicare & Medicaid Services (CMS).
2013 Actuarial Report on the Financial Outlook for Medicaid.
https://www.cms.gov
Kaiser Family Foundation (KFF).
Medicaid Enrollment and Spending Growth: FY 2013–2023 Trends and Forecasts.
https://www.kff.org/medicaid/
U.S. Congress.
H.R. 1 – Tax Reform Reconciliation Act of 2025. Sections 71101–71120.
https://www.congress.gov/bill/119th-congress/house-bill/1
Congressional Budget Office (CBO).
Federal Subsidies for Health Insurance Coverage: 2023 to 2033.
https://www.cbo.gov/publication/59152
California Department of Finance.
Medi-Cal Emergency Federal Support Request and FY 2024 Budget Stabilization Report.
https://dof.ca.gov
National Conference of State Legislatures (NCSL).
State Medicaid Expansion Decisions and Status Map. Updated 2024.
https://www.ncsl.org/health/medicaid-expansion-status-map
Medicaid and CHIP Payment and Access Commission (MACPAC).
Medicaid Enrollment Snapshot Report, FY 2023.
https://www.macpac.gov/publication/medicaid-enrollment-trends/
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