Federal Medicaid cuts threaten health care for thousands in D.C.

Dr. Randi Abramson has spent years urging her patients to keep up with vaccinations and preventive care. Now, they don’t seem to need the reminders.

At Bread for the City, patients aren’t waiting to schedule check-ups. They’re double-checking their immunization records, refilling prescriptions and asking Abramson what else they might need while they still have coverage. Some are coming in for long-overdue visits. Others are trying to prepare for the possibility—if not the likelihood—that they’ll soon lose their Medicaid coverage.

Normally, Abramson would welcome the urgency. But this isn’t about staying on top of routine care—it’s about fear. With proposed federal cuts looming, many of her patients worry they’ll lose access to the doctors, medications and treatments they rely on.

“Our patients are really nervous and really scared, and rightly so,” says Abramson, Bread for the City’s medical director.

A looming budget crisis for the District

Since taking office, President Donald Trump, Republicans in Congress and Elon Musk’s Department of Government Efficiency have pushed to slash federal spending by up to $2 trillion to offset $4.5 trillion in proposed tax reductions. Their proposals include reductions across federal agencies affecting multiple social safety net programs, including housing assistance and food security. But Medicaid—the nation’s largest public health insurance program, which provides coverage to millions of low-income Americans—has drawn particular attention as lawmakers look for ways to achieve large-scale budget cuts.

Last month, House Republicans passed a budget resolution directing the Energy and Commerce Committee, which has jurisdiction over healthcare programs including Medicaid, Medicare, and the Children’s Health Insurance Program (CHIP), to cut at least $880 billion over the next decade. 

Though the resolution doesn’t explicitly mention Medicaid, experts say it would be nearly impossible to meet that target without touching the program. Medicare and Social Security account for a large share of federal spending, but past efforts to cut those programs have faced significant political opposition. That leaves Medicaid as the most vulnerable.

So what’s the local impact? As part of these cost-cutting efforts, Congressional Republicans are considering reducing D.C.’s federal Medicaid match rate from 70% to 50%. This change would significantly shrink the federal funding D.C. receives for the program, shifting a greater financial burden to the city. Another proposal would lower the federal match rate for Medicaid expansion from 90% to 50%, requiring the District to cover a much larger share of healthcare costs for low-income adults.

For states and territories, including D.C., that rely heavily on federal Medicaid reimbursements, these cuts would create a massive budget hole. Deputy Mayor for Health and Human Services Wayne Turnage warned earlier this year that the proposed Medicaid cuts could leave D.C. with a $2.1 billion budget shortfall, effectively rolling funding levels back to what they were in 2017.

The cuts would fall hardest on low-income adults, children and residents covered through the Affordable Care Act expansion—who make up more than half of D.C.’s Medicaid population. As of August 2024, more than 140,000 of the city’s 264,000 Medicaid enrollees are enrolled through the expansion group, according to the Kaiser Family Foundation.

Adding to the pressure, Turnage noted that Medicaid costs have already been rising faster than the city can keep up with. In fiscal year 2026 alone, Turnage estimates the District will need an additional $173 million to sustain current Medicaid services. Over four years that shortfall is expected to grow to $580 million, adding further strain to the city’s budget.

“It's a complex challenge, and it will take some creative thinking, and at the end of the day, decisions that may not be avoidable,” he said during a performance oversight hearing in February.  “And what makes this so challenging is the Medicaid program serves — obviously — the most vulnerable populations in the city.”

In a written statement to The 51st, Turnage acknowledged the scale of the shortfall and said his department is preparing for the possibility of significant budget reductions.

“Despite these significant challenges, the mission of DHCF remains the same,” Turnage said in the statement. “To improve health outcomes by providing access to comprehensive, cost-effective, and quality healthcare services for residents of the District of Columbia and we will continue to do so this year, even in uncertain times."

The financial pressures on the city don’t end there. Even before these potential Medicaid cuts, D.C. was already bracing for a budget shortfall. In February, the Office of the Chief Financial Officer revised the city’s revenue forecast downward by $1 billion over the next four years, citing falling commercial real estate values, declining income tax revenue and economic slowdowns tied to federal workforce reductions.

Compounding the crisis, the city is also caught in a budget standoff with Congress.

Earlier this month, House Republicans attempted to cut more than $1 billion from the city’s current budget, a move local officials warn would force reductions to essential services, including police, fire and emergency response, education and public health programs. While the Senate unanimously passed a fix to restore the funds, the House has yet to act, leaving D.C.’s budget—and critical services—in limbo.

The strain on D.C.’s healthcare system

The potential Medicaid cuts would hit D.C.’s most vulnerable residents the hardest, particularly people of color, women, seniors and individuals with disabilities. More than 95% of non-elderly Medicaid enrollees in D.C. are people of color, and Medicaid covers nearly half—45%—of all births in the District, according to the Kaiser Family Foundation.

For many, Medicaid isn’t just a healthcare option—it’s the only option. Nearly one in four D.C. residents, or 24% of the population, is covered by Medicaid or CHIP, and 23% live below 200% of the federal poverty level. Many work in industries without employer-sponsored insurance, leaving them with few alternatives if coverage is reduced or eliminated. Without Medicaid, some would have no choice but to delay treatment, increasing the likelihood of severe health complications and costly emergency room visits.

Emergency rooms are “already just flooded and a very expensive way to deliver care,” Abramson says. 

The stakes are especially high for Black residents, who make up roughly three-quarters of Medicaid enrollees. Black residents in D.C. already face disproportionately high rates of hypertension, diabetes, and heart disease, conditions that require consistent care. Many depend on community health centers like Bread for the City for routine care, chronic disease management and maternal health services, which are essential resources that could be significantly reduced or eliminated if funding is cut. 

“The path to ending health disparities runs straight through community health centers. The primary care they provide is the key to preventing and managing chronic disease,” says Ruth Pollard, president and CEO of the D.C. Primary Care Association. “ Primary care is the only segment of the health system where increased investment is proven to improve population health. Anything that reduces primary care will exacerbate disparities.”

Beyond primary care, Medicaid also supports long-term care and managed care services, which make up 30% and 43% of total Medicaid spending in D.C., respectively. Cuts to these programs could destabilize essential services for seniors and individuals with disabilities, limiting access to in-home care, nursing facilities and disability support programs that help them live independently. Without Medicaid funding, many would face significant disruptions in care, putting their health and stability at risk.

Community health clinics brace for the worst-case scenario

D.C. has nine community health centers, including eight federally qualified health centers. These centers provide integrated medical, dental and behavioral health services at more than 62 locations. Unlike hospitals, which have a mix of revenue sources, FQHCs rely almost entirely on Medicaid reimbursements and grant funding to keep their doors open.

Pollard says if the proposed Medicaid cuts go through, D.C.’s community health centers could lose $58 million in funding. That would put coverage at risk for more than 90,000 childless adults and more than 34,000 patients who receive care at community health centers.

“We already see a large gap of life expectancy between Northwest and Southeast DC,” Pollard says. “DCPCA projects that the proposed cuts would further worsen the disparity and limit access to high-quality healthcare.”

Kelly Sweeney McShane, president and CEO of Community of Hope, a nonprofit health provider that operates three of the District’s eight FQHCs, says more than a third of the organization’s operating budget depends on Medicaid reimbursements. “It’s a significant chunk,” she says.

McShane estimates that about 70% of their patients—roughly 11,500 people—rely on Medicaid for healthcare. While she doesn’t expect every patient to lose coverage, even a small reduction could force thousands to delay or forgo care.

“Community of Hope does have a sliding fee scale, but again, if we have a lot more people who are uninsured, we'd have to kind of take a look at our underlying business model and what services we could offer,” she says.

Other local providers also say Medicaid cuts could destabilize the entire financial model that keeps community health centers operating.

Ashley Domm, chief development officer at Bread for the City, says Medicaid reimbursements are essential not just for medical supplies and operations but for paying the people who provide care. Sixty percent of Bread for the City’s patients rely on Medicaid, and those funds cover a significant share of the budget, including salaries for doctors, nurses and support staff.

A loss of funding could mean reduced hours, limited services, or even staff cuts. And relying on philanthropy, Domm adds, is not a sustainable solution.

“Philanthropists don't have a trillion dollars,” she says. “So, it's going to become like a bit of a scarcity model because while all of the philanthropists… want to support their communities… the dollars just aren't there.”

If Medicaid reimbursements decline, some health centers may not survive. But if FQHCs struggle or shut down, healthcare officials argue the burden will shift elsewhere. Instead of visiting their primary doctor for routine care, more patients will be forced to delay treatment until conditions become emergencies, overwhelming hospitals and driving up uncompensated care costs.

Domm sees it as a dangerous domino effect that would hurt patients, hospitals and the city’s overall healthcare system.

“We're providing that essential primary care,” she says. “It costs taxpayers so much money for low-income people to not have access to primary care and to get their primary care at the hospital when things go bad because they didn't have preventative care.”