Speaker Mike Johnson defended the Medicaid provisions in President Trump’s sweeping new domestic policy bill on Sunday, arguing that nearly five million Americans wouldn’t lose coverage “unless they choose to.” His comments, made on NBC’s Meet the Press, came amid growing criticism from health care advocates, economists, and even some Republicans that the bill’s work requirements will disproportionately harm Trump’s own voter base particularly low-income rural communities that heavily rely on Medicaid.
Johnson dismissed projections from nonpartisan analysts that show approximately 4.8 million people could lose Medicaid access due to new eligibility hurdles, including strict work or volunteer requirements. “Those 4.8 million people will not lose their Medicaid unless they choose to do so,” he told host Kristen Welker. “If you’re a healthy young man, and you can’t manage 20 hours of work or volunteering in your community, that’s a choice. That’s not a denial of benefits.”
He insisted that the rules are rooted in “common sense,” framing the changes as beneficial for personal dignity and community engagement. “When people work, it’s good for them and for the community,” Johnson said. “This isn’t a punishment it’s an opportunity.”
But critics, including some within the GOP, say that framing misses the reality on the ground. Many of those projected to lose coverage are from economically depressed regions where work and volunteer opportunities are scarce, and where even minor administrative barriers like complex paperwork or inconsistent internet access can lead to dropped benefits. These are often the same regions that powered Trump’s victories in 2016 and 2024.
The bill, which Johnson has dubbed “big and beautiful,” would require states to enforce work requirements for childless adults aged 19 to 64 in order to qualify for Medicaid. It would also shorten the Affordable Care Act’s open enrollment period, potentially reducing access to private insurance for thousands more Americans. The Congressional Budget Office and several independent think tanks have warned that these changes could lead to widespread disruptions in care.
Republican strategists have quietly expressed concern that the policy could backfire politically. Many Trump voters in red states benefit directly from Medicaid or rely on rural hospitals that are propped up by the program. By tightening access, critics argue, the GOP risks alienating key constituencies in states like West Virginia, Missouri, and Kentucky.
While Johnson insists the policy promotes responsibility, opponents argue it’s a veiled form of austerity that punishes the poor and vulnerable a move that may play well with fiscal conservatives but not with Trump’s working-class base, who are already feeling squeezed by rising costs and economic uncertainty.
As the bill advances in the Senate, pressure is building on Republican lawmakers to revise the provisions or risk triggering a backlash in their own backyard.