If you want to save money, you need to deny healthcare to sick people. As politically unappealing as it may be to deny insulin to diabetics, or to refuse chemotherapy to cancer patients, it’s really the only option to achieve savings. Remember that rule of thumb about how 80 percent of the money goes to treat the sickest 20 percent of enrollees; if policymakers want to achieve savings, they need to be laser-focused on not paying for healthcare for those sickest 20 percent.

And policymakers could certainly pursue that option! There is a foolproof way to save money on Medicaid, which is to let sick people who are kicked off Medicaid simply die in the street. When a guy rolls into the ER on a gurney after a traffic accident, we as a society could shrug and say “he didn’t properly fill in the paperwork to show his employment status back in March, so he’s out of luck,” and let him bleed out. We’d have saved perhaps hundreds of thousands of dollars in ICU costs at a single stroke.

But there are substantial practical problems with this approach to saving money on Medicaid, which are that (1) it’s morally reprehensible, (2) it’s politically toxic, and (3) it violates long-established state and federal law regarding hospitals’ obligation to provide emergency care.

Because of these practical obstacles, politicians have hunted for other approaches to disguise what they’re doing. They require hospitals to treat uninsured people in emergencies, and provide billions in state and federal funding to compensate them for that care. They pass laws like the Big Beautiful Bill Act that kick millions off Medicaid, but add carveouts for those with “serious or complex” medical conditions. And then they tell the public “well, we’ll cut off Medicaid, but only to healthy people.” We’re going to achieve some Medicaid savings, yes, but we’re not monsters; we won’t let people die in the street.