(Getty Images).The Congressional Budget Office estimated that the legislation President Donald Trump called the “One Big Beautiful Bill” would increase the federal deficit by $3.4 trillion over a decade, despite its massive cuts to healthcare and food assistance. It was designed so that its worst impacts wouldn’t be felt until after the midterm elections.
Now the midterms are nigh, and Missouri has done too little to mitigate the coming pain.
Cuts to Medicaid are not popular. That’s why congressional Republicans denied they were cutting Medicaid in the legislation. And yet, Republicans looking for offsets to renew tax cuts passed in the first Trump administration found what the CBO estimates will be a $911 billion reduction in federal Medicaid spending over a decade. The law is expected to leave 10 million more Americans uninsured.
Health policy organization KFF estimates $326 billion of the Medicaid spending reductions will come from the legislation’s imposition of “work requirements” on people who are eligible for Medicaid through the Affordable Care Act expansion. Numerous studies show that people on Medicaid who can work are already working. Work requirements do not increase employment, just paperwork.
The savings will come from working poor people and people too disabled to work losing their health insurance, despite remaining eligible, because of administrative burdens that they can’t handle — or their states can’t handle.
Missouri is terrible at administering benefits generally and particularly unprepared for this.
From January 2025 through February 2026, 333,265 Missourians lost Medicaid coverage, 91.9% of them not because the Missouri Department of Social Services found them ineligible, but for paperwork reasons.
People lose coverage when they don’t receive their renewal letters, when the letters are confusing, when their work hours vary, when they can’t get ahold of the department after hours on hold, when the agency loses their documents or when the agency receives their documents but doesn’t process them before the computer automatically terminates their coverage.
That’s without the federal work requirements that take effect on Jan. 1, 2027. It’s also without the new federal requirement that Medicaid expansion enrollees renew every 6 months. Imposing that hurdle is expected to “save” another $63 billion when eligible people lose their insurance.
Georgetown University’s McCourt School of Public Policy is tracking states’ readiness to implement the law’s Medicaid requirements across eight metrics: call center wait times, call abandonment rates, application processing times, renewal rate, ex parte renewals (when the state uses data it already has to determine eligibility), disenrollments at renewal, disenrollments for procedural reasons and pending renewals. Missouri was one of three states to earn a red flag for 7 of the 8 metrics.
Cuts to the Supplemental Nutrition Assistance Program, or “SNAP,” formerly known as food stamps, will bring additional hardship. The law delays one major change until after the midterms: Beginning in October 2027, states with sufficiently high payment error rates will have to pay a portion of SNAP benefit costs for the first time. How much they pay will depend on their error rates, which measure overpayments and underpayments, often resulting from minor mistakes.
Missouri has a history of failing to administer SNAP in compliance with the law. A federal lawsuit documented disabled people waiting on hold with the department’s call center for many hours only to have their calls dropped and their applications terminated.
On Oct. 1, Missouri began requiring applicants and people renewing their SNAP benefits to provide additional documentation of their eligibility, in an apparent attempt to lower the error rate that will determine how much Missouri must pay for SNAP.
Missouri’s error rate dropped from 9.42% in 2024 to 8.26% in 2025. But in the eight months after Missouri’s more stringent documentation requirements went into effect, 46,630 fewer Missourians received benefits.
If Missouri’s error rate stays in the same range, the state will need to pay an estimated $150 million previously covered by the federal government.
The “One Big Beautiful Bill” has been a freight train headed toward us for a long time. Our representatives did nothing to stop it and little to prepare for it. U.S. Sen. Josh Hawley did so much talking about his opposition to Medicaid cuts, some of us thought he was serious. Instead he voted for the legislation despite it having $340 billion more cuts on top of the work requirements. Those cuts put an estimated 446 hospitals at risk of closing, nine of them in Missouri. Hawley said he’d work to restore the funding just after he voted to cut it. That entailed introducing a messaging bill that has no chance of going anywhere.
U.S. Sen. Eric Schmitt and all of our Republican Congressional representatives voted for it as well.
With the freight train approaching, our Republican state lawmakers put their all into an attempt to eliminate the income tax that voters rejected in August. A plan for filling our coming $1.7 billion budget hole has not been forthcoming.
The math ain’t mathin’. Republicans knew it was never going to, but they were clever enough to evade accountability by pushing the pain past the midterms.
