Trump, Project 2025 and the Social Safety Net

Project 2025 called Medicaid, a federal-state program that provides health care for low-income people, a “cumbersome, complicated, and unaffordable burden on nearly every state,” and “a prime target for waste, fraud, and abuse.”

The document targeted Medicaid’s funding structure for change, saying it “rewards expansions.” In particular, it criticized the Affordable Care Act for expanding Medicaid to include more people.

The ACA allowed states to expand Medicaid to adults under 65 who earn up to 138% of the federal poverty level and, in exchange, the federal government would permanently pay 90% of the cost. Forty states and Washington, D.C., have implemented that Medicaid expansion, which added an estimated 21.3 million people as of last year, according to KFF, a health policy research group.

Project 2025 suggested that the expansion of Medicaid is the reason why “[i]mproper payments within Medicaid are higher than those of any other federal program.” It claimed, “These payments are evidence of the inappropriateness of Medicaid’s expansion.” (Improper payments include overpayments and underpayments or payments that shouldn’t have been made. Experts have told us this often is due to missing paperwork.)

One solution proposed by Project 2025: “Clarify that states have the ability to adopt work incentives for able-bodied” Medicaid recipients. In his first term, Trump “encouraged states to apply for Section 1115 waivers that included work and reporting requirements as a condition of Medicaid eligibility.” Only Arkansas implemented work and reporting requirements “with consequences for noncompliance, resulting in 18,000 losing coverage,” according to KFF. 

“Courts struck down many of the waiver approvals, including in Arkansas, and the Biden administration rescinded the remaining waivers, or they were withdrawn by the states,” KFF said.

This time, Trump went beyond what he did in his first term and what Project 2025 had proposed. 

As we’ve written, Trump’s One Big Beautiful Bill Act mandates national work and reporting requirements, with some exceptions, for those who gained coverage under the ACA’s Medicaid expansion provision. The new law “[r]equires able-bodied adults aged 19-64 to work (or perform other qualifying activities) for at least 80 hours a month,” as explained by the Association of State and Territorial Health Officials, a bipartisan organization. 

The law exempts “pregnant women, those with serious medical conditions, tribal members, parents/caregivers of a dependent child 13 years and under or with a disability” from the work and reporting requirements, the organization said, adding that the work requirements must take effect no later than Dec. 31, 2026. 

“Mandating that adults who are eligible for Medicaid through the ACA expansion meet work and reporting requirements” will reduce federal spending on Medicaid by $386 billion over 10 years – making it the largest source of Medicaid savings in the law, KFF said in a July 23 article based on the Congressional Budget Office’s July 21 cost estimate. 

In all, the new law will cut Medicaid spending by $911 billion over 10 years, according to a KFF analysis, and increase the number of uninsured people in the U.S. by 10 million, according to the CBO, with 7.5 million of those due to changes to Medicaid.

Holland & Knight, a Florida-based lobbying and law firm, said the impact of the Medicaid cuts, which also include limits on provider taxes states have used to help finance the program, “will vary from state to state,” adding that “states may cut Medicaid services, tighten eligibility and redetermination requirements, and/or reduce Medicaid provider payments.”

More than 42 million Americans receive food assistance through the Supplemental Nutrition Assistance Program, or SNAP, which was once known as the food stamp program. There have been work requirements for food assistance for decades. 

Under the current work rules, able-bodied adults between 16 and 59 years old must register for work and participate in state training programs; they cannot voluntarily quit a job or reduce their hours to less than 30 hours per week; and they cannot refuse to take a “suitable” job offer, according to the U.S. Department of Agriculture, which administers SNAP. 

There are exemptions for some, including some students, the disabled and those caring for children under 6 years old, as the USDA explains. For those age 18 to 54 without dependents, there are additional work requirements that, if not met, limit assistance to three months in three years, with exemptions for veterans and pregnant people, among others.

Project 2025 said the next conservative president should “[r]eform SNAP.” It called the work requirements for SNAP “fairly limited” and criticized the waiver process that it said makes it too easy for states to obtain waivers for Able-Bodied Adults Without Dependents. 

The document recommended strengthening the work rules, which Trump tried unsuccessfully to do in his first term. Project 2025 urged the next president to try again — and this time Trump was successful, thanks to the One Big Beautiful Bill Act that he signed in July.

The new law expands “the population subject to SNAP’s Able-Bodied Adults Without Dependents work requirements by including adults 55-64 years of age” and those with children 14 to 17 years old, as well as “making it harder for areas of states to qualify for a waiver from the work requirements,” according to the Congressional Research Service, the nonpartisan research arm of Congress. The Aug. 15 report said the law also phases out exemptions for “veterans, individuals experiencing homelessness, and certain individuals who aged out of foster care.” When the new work requirements take effect depends on USDA rulemaking and “may be subject to flexibilities given to states in federal regulation,” the CRS report said. 

An estimated 2.4 million fewer people will have SNAP benefits due to the expanded work requirements and tightened restrictions on states’ ability to waive work requirements, according to an Aug. 11 CBO report.

The new law, among other things, also limits the USDA’s authority to raise monthly SNAP payments, increases state cost-sharing requirements and eliminates required funding for the Nutrition Education and Obesity Prevention Grant Program, also known as SNAP-Ed, CRS said. 

The Urban Institute estimated that 22.3 million families will “lose some or all of their SNAP benefits” as a result of the new law. 

In its July 21 report, CBO estimated that the new law will reduce SNAP funding by approximately $186 billion over 10 years. (See Title I, subtitle A of the CBO cost estimate.)

In a section written by Trump’s former Housing and Urban Development Secretary Ben Carson, Project 2025 proposed a major overhaul of HUD and the nation’s rental assistance programs, claiming “HUD programs tend to perpetuate the notion of bureaucratically provided housing as a basic life need and, whether intentionally or not, fail to acknowledge that these public benefits too often have led to intergenerational poverty traps.”

The document called for Congress to “consider a wholesale overhaul of HUD that contemplates devolving many HUD functions to states and localities.” That is exactly what Trump has proposed in his first budget to Congress earlier this year, along with deep cuts in housing assistance.

On May 2, the White House Office of Management and Budget submitted a summary of Trump’s budget proposal for fiscal year 2026 that would combine five rental assistance programs into a single state-administered grant program.

The proposed State Rental Assistance Block Grant would receive nearly $31.8 billion, according to OMB’s more detailed Technical Supplemental to the 2026 Budget. The proposed restructuring would result in a reduction of $26.7 billion in housing assistance, the budget summary said.

That amounts to a 43% reduction in the five programs, according to the National Low Income Housing Coalition. The programs currently provide housing assistance to nearly 4.5 million households for low-income families, seniors and disabled, OMB said.

Of the programs that would be turned over to the states, the Tenant-Based Rental Assistance, also known as the Housing Choice Voucher Program, is the “largest income-targeted rental assistance program,” according to OMB’s more detailed Technical Supplemental to the 2026 Budget. That program provides “housing assistance to approximately 2.3 million extremely low- to very low-income families,” the budget document said.

Here is a list of the four other housing programs that would be affected and the number of families or households that currently benefit from the programs, according to the OMB: Project-based Rental Assistance Program (1.2 million), Public Housing Fund (800,000), Housing for the Elderly (120,000) and Housing for Persons with Disabilities (33,000). 

The budget proposal also would place a cap on housing assistance to promote self-sufficiency – another Project 2025 recommendation for HUD.

“This program would promote self-sufficiency by instituting a two-year cap on rental assistance for able-bodied, working age households, and would ensure the majority of assistance funded through the states would go to the elderly or disabled,” OMB said in the budget supplement.   

According to HUD, households receiving rent subsidies generally “pay rent equal to 30 percent of their incomes, after deductions, while the federal government pays the remainder of rent or rental costs.”

But in spending bills passed earlier this year, congressional appropriators rejected Trump’s plan to convert the housing assistance programs into a single state block grant program. 

In those bills, the Senate Appropriations Committee increased funding for all five assistance programs, but the House committee cut funding for two programs – Tenant-Based Rental Assistance and Public Housing Fund  – by nearly $2 billion. 

Project 2025 identifies Medicaid and Medicare as a primary driver of annual deficits and the cumulative U.S. debt, identifying both as “runaway entitlements.” 

“In essence, our deficit problem is a Medicare and Medicaid problem,” the document says. 

As we mentioned earlier, Trump has made significant cuts to Medicaid spending, but not Medicare. However, the new law did make some changes to Medicare — including “two very important changes,” one of which will result in the loss of Medicare coverage for noncitizens, Gerard Anderson, a professor in health policy and management at Johns Hopkins University’s Bloomberg School of Public Health, said in a Q&A on the impact of the new law on public health.

“Currently, immigrants with legal status can meet eligibility requirements to qualify for Medicare,” Anderson said. “The new legislation restricts eligibility to only U.S. citizens, green card holders, and legal immigrants from a few specific locations. This means that even immigrants who have followed the rules—including refugees, people granted asylum, people with temporary protected status, and even permanent residents—will lose coverage.”

The new law also delays implementation of changes that the Biden administration made in 2023 to the Medicare Savings Programs, which provide subsidies for low-income Medicare beneficiaries. The changes were designed to make it easier to enroll in the programs, which use Medicaid dollars to pay Medicare premiums and cost-sharing. 

“Millions of individuals with limited income and resources rely on the Medicare Savings Programs (MSPs) to help cover Medicare Parts A and B premiums and, often, cost-sharing,” according to a Biden-era rule finalized in September 2023 that made it easier to enroll in the programs. “Through the MSPs, Medicaid pays Medicare Part B premiums each month for over 10 million individuals and Part A premiums for over 700,000 individuals. However, millions more are eligible but not enrolled.”

“This legislation blocks that rule from being implemented until 2034,” Liz Fowler, who is affiliated with Johns Hopkins’ health policy and management department, said in the Q&A with Anderson. “This delay will impact low-income individuals who need this cost-sharing support to afford things like prescription drugs, medical supplies, hospital stays, and nursing facility care.” 

The CBO estimated that the moratorium on implementation of the Medicare Savings Programs rule will reduce costs by about $66 billion over 10 years. (See Title VII, subtitle B of the CBO cost estimate in the July 21 report.)

Although unlikely, more Medicare cuts could be coming.  

The CBO – the official congressional budget scorekeeper – estimated in its July 21 report that the new law will increase the budget deficit by an estimated $3.4 trillion over 10 years, which would trigger mandatory cuts to Medicare under the Statutory Pay-As-You-Go Act of 2010 – unless Congress acts to waive or the change the rule. 

Without congressional action, the required reductions in Medicare spending would total $536 billion over nine years, beginning in fiscal year 2026, CBO told Congress in an Aug. 15 letter. However, CBO noted in a June letter to Sen. Lindsey Graham that such cuts, known as sequestration, have never been triggered because Congress has taken action to prevent cuts.

The left-leaning Center for American Progress said Congress will have to act by mid-January to avoid cuts for fiscal year 2026.

In addition to the program changes, the Department of Health and Human Services has reduced staffing at the Centers for Medicare & Medicaid Services by about 300 employees.

Project 2025 recommended eliminating Head Start, a federal initiative that provides grants for 1,600 local agencies that help more than 700,000 low-income children prepare for school. The document called it “fraught with scandal and abuse.”

Trump’s fiscal year 2026 budget did not propose eliminating Head Start, despite reports in April that the administration targeted Head Start for elimination in an earlier draft budget document. 

In its fiscal year 2026 budget, HHS proposed keeping Head Start funding unchanged at about $12.27 billion from funding levels in FY2024 and FY2025. 

Still, preschool advocates are concerned about the future of the program. 

In a May 30 statement on the HHS proposed budget for FY2026, Yasmina Vinci, executive director of the National Head Start Association, said level funding “for a third consecutive year … is effectively a deep cut.”

“Head Start programs are facing significant pressures: rising costs, workforce shortages, and increasing demand for comprehensive early childhood services,” Vinci’s statement said. “Maintaining funding for a third consecutive year — without accounting for inflation, workforce competition, or increased needs — is effectively a deep cut. It means programs will be forced to make impossible choices, including reducing enrollment, cutting hours, or laying off staff.”

Also, earlier this year, HHS closed five of 10 regional offices that fund and support Head Start programs.   

The closed regional offices were located in the cities of New York, Boston, San Francisco, Seattle and Chicago. 

Although Head Start was spared from being zeroed out entirely, the proposed HHS budget would eliminate the Preschool Development Grant Birth through Five program, a $315 million federal grant program that helps states improve their preschool programs. “PDG literally does not fund any preschool for children and their families,” according to an OMB summary of Trump’s budget proposal. That’s true, but the money does “support the broader early childhood ecosystem, including data systems, quality enhancements, and other related programs,” according to New America, a left-leaning think tank that focuses on education among other policy areas.  

In addition, the proposed Education Department budget would eliminate IDEA Part B, Section 619, which funds preschool for children with disabilities age 3 to 5. However, the OMB budget summary says the preschool grants would be combined with six other grant programs under the Individuals with Disabilities Education Act, or IDEA Act. Overall, the IDEA Grants to States program would increase $677.5 million to a total of $14.9 billion in FY2026, the department said in a budget document.