There is an assumption buried underneath many American conversations about poverty that deserves far more scrutiny than it receives. If someone is poor, we assume that person must not be doing enough. Work more. Budget better. Become more independent. Stop relying on government assistance. Take greater personal responsibility. Those ideas have enormous political power because they allow poverty to be interpreted not simply as an economic condition, but as evidence of individual failure. Once that assumption is accepted, policies that make assistance harder to receive can be presented as accountability rather than reductions in access.

As a public health educator and mother to disabled children who will need lifelong care, I cannot look at these policies only as numbers on a government spreadsheet. I understand the conservative argument for fiscal restraint. Government programs should be accountable, fraud should be investigated, public money should be spent responsibly, and assistance programs should reach the people for whom they were created. None of those principles requires me to pretend that every policy described as fiscal responsibility distributes its sacrifices responsibly.

That distinction has become increasingly important since the enactment of Public Law 119 21, the federal reconciliation law signed in July 2025. The Congressional Budget Office projects that changes made by the law will reduce federal Medicaid spending by approximately $1.2 trillion between 2026 and 2035. CBO expects Medicaid enrollment to be 13.1 million lower in 2035 as a result of those changes. Looking specifically at 2034, CBO estimates that the Medicaid provisions will leave approximately 7.5 million additional people without health insurance. The same law is projected to reduce federal Supplemental Nutrition Assistance Program spending by approximately $211 billion through 2035 because fewer people will participate, average benefits will fall, and states will assume a greater share of program costs (Congressional Budget Office [CBO], 2026).

Those numbers require some care. Not every person represented in the Medicaid enrollment reduction is disabled, and not every enrollment reduction equals an uninsured person. CBO notes that approximately 1.5 million of the enrollment records affected in its 2034 estimate reflect duplicate enrollment records, meaning those individuals would retain Medicaid eligibility in their state of residence (CBO, 2026). Precision matters, particularly when discussing policies this politically charged. But precision does not make the overall effect small. Millions of people are still expected to lose health coverage, while hundreds of billions of dollars are being removed from programs that disproportionately serve people with low incomes, serious health needs, children, older adults, caregivers, and people with disabilities.

When Work Requirements Become Coverage Requirements

One of the central features of the Medicaid changes is a federal work and community engagement requirement. Beginning in 2027, affected Medicaid expansion adults will generally be required to demonstrate 80 hours per month of employment, education, training, community service, or another qualifying activity unless an exemption applies. Supporters describe the policy as encouraging employment and ensuring that public assistance is connected to personal responsibility. That deserves to be stated fairly. What also deserves to be stated is how the federal government actually realizes the savings. The government spends less because fewer people remain enrolled.

That distinction matters because losing Medicaid is not evidence that every person removed from the program was committing fraud, refusing to contribute, or sitting comfortably at home waiting for taxpayers to provide everything. Medicaid eligibility and successful documentation of Medicaid eligibility are two different things. Administrative requirements can remove people who no longer qualify, but they can also remove eligible people who miss notices, fail to provide documentation correctly, misunderstand an exemption process, experience interruptions in work, or simply cannot navigate the system successfully.

People living with unstable health are especially difficult to fit into neat administrative categories. Disability does not always arrive with a Social Security award letter and a tidy government classification. Some people can function productively for periods of time and then experience weeks when their bodies will not cooperate. Others live with conditions that substantially limit employment but do not meet the legal definition necessary for another disability program. Caregivers may technically be capable of employment while simultaneously providing substantial unpaid care that makes conventional employment difficult to sustain.

Policy likes clean categories. Human bodies remain stubbornly uninterested in cooperating with them.

The problem, therefore, is not that government expects accountability. The problem begins when access to health care increasingly depends on successfully navigating administrative tests in addition to meeting the underlying eligibility requirements. Public policy research has repeatedly distinguished between substantive eligibility and procedural disenrollment for precisely this reason. If someone qualifies for coverage but loses it because of paperwork, the government spreadsheet still records reduced enrollment and lower spending. The human outcome is considerably less tidy.

Poverty Is Becoming an Administrative Job

This is where the cultural insistence that poor people simply need to do more becomes particularly difficult to defend. Low income households already navigate income verification, household reporting, renewal notices, medical documentation, employment changes, appointment schedules, transportation problems, childcare, disability evaluations, benefit notices, and deadlines. Increasing the frequency of those interactions does not merely create accountability. It creates administrative burden.

The 2025 federal law changes Medicaid eligibility requirements, enrollment processes, and financing simultaneously. CBO concluded that these provisions will account for most of the projected $1.2 trillion reduction in Medicaid spending through 2035 (CBO, 2026).

Again, that reduction is called savings because federal expenditures become smaller. That tells us what happens to one government account. It does not tell us what happens to the need.

If a person loses medication coverage and becomes sicker, the medical condition does not disappear. If home based support becomes unavailable and a relative reduces paid employment to provide care, the caregiving need does not disappear. If preventive treatment is delayed until an emergency department becomes the only remaining option, the health care cost does not disappear. If a disabled person can no longer remain safely in the community and eventually requires institutional care, the need certainly does not disappear.

A government can eliminate a cost. A government can also transfer a cost. Those are not the same achievement, even when both make the same line on a federal spreadsheet smaller.

SSI and the Price of Having Somewhere to Sleep

A similar philosophy is appearing in Supplemental Security Income, a program specifically designed for people who are disabled, blind, or at least 65 and who also have very limited income and resources.

In 2024, the Social Security Administration expanded the definition of a public assistance household for SSI purposes. The change added SNAP to the qualifying public income maintenance programs and allowed a household to qualify when an SSI applicant or recipient lived with at least one other household member receiving qualifying public assistance. Previously, every household member generally had to receive qualifying public assistance. SSA explained that the expansion would allow more people to qualify for SSI, increase payments for some recipients, and reduce administrative burdens for both low income households and the agency (Social Security Administration [SSA], 2024).

The reason is buried inside one of the more bureaucratic phrases in the federal benefits system, in kind support and maintenance. SSI can treat shelter provided by another person as a form of income. Social Security explains that when another person provides or pays for shelter, that assistance can reduce the amount of SSI a recipient receives (SSA, 2025).

The Trump administration is now pursuing a rescission of the expanded public assistance household definition. SSA oversight documents report that the proposed reversal would remove SNAP from the qualifying list and return to the former definition under which every household member generally must receive qualifying public assistance before the household receives the protection. SSA has stated that the proposed reversal is intended to promote program integrity and address administrative burdens and costs associated with implementing the 2024 rule (Social Security Administration Office of the Inspector General [SSA OIG], 2026).

That rationale should be considered. So should what the rule means when translated out of administrative English.

A disabled adult who cannot afford independent housing may live with a parent or another family member. That household may itself be poor enough to receive SNAP. Under the expanded protection, SSA may not need to treat shelter provided within that qualifying household as in kind support that reduces the SSI payment. Reversing the protection potentially exposes more recipients to those calculations again.

In other words, the family can be poor enough to need food assistance, the disabled adult can be poor enough to qualify for SSI, and the government can still potentially determine that the bedroom keeping that person from homelessness represents economic support that justifies reducing the SSI benefit.

Apparently the family bedroom has become an asset class.

The rescission has not become a final rule, and it would be inaccurate to write as though hundreds of thousands of SSI checks have already been reduced. They have not. The distinction between enacted policy and proposed policy matters. The direction of the proposal matters too, particularly because SSA previously described the expanded rule as a way to reduce reporting burdens and simplify administration for low income households (SSA, 2024).

Then Federal Policy Arrives in Idaho

Federal policy does not remain in Washington. States implement it, interpret it, administer it, and sometimes add their own layers.

Beginning January 1, 2027, Idaho Medicaid expansion recipients will generally have to demonstrate 80 hours per month of work, education, training, volunteering, or another qualifying activity unless they qualify for an exemption. New applicants must demonstrate compliance during each of the three months before applying. Existing recipients will be reviewed for compliance during six month periods, and Idaho will also confirm continued Medicaid eligibility every six months (Idaho Department of Health and Welfare [IDHW], 2026a).

That is an important distinction for discussions about disability. Idaho Medicaid expansion itself serves adults who are not enrolled through the categorical disability Medicaid programs. Exemptions exist for qualifying circumstances, and it would be inaccurate to say that every formally disabled Medicaid recipient is being ordered to complete 80 hours of work. The vulnerability lies partly among people whose illnesses, functional limitations, caregiving obligations, or changing circumstances do not fit neatly into a categorical disability designation or who must successfully establish an exemption.

Idaho is simultaneously transforming its broader Medicaid system. House Bill 345, enacted in 2025, directs the state toward comprehensive managed care. Idaho Department of Health and Welfare states that all populations and nearly all services are expected eventually to enter managed care unless federal law requires an exception, with intellectual and developmental disability services transitioning later. The department currently expects comprehensive managed care implementation in 2030 (IDHW, 2026b).

The same state guidance contains a remarkable sentence about beneficiary costs. Idaho law requires Medicaid cost sharing at the highest level approved by any state, and the transition to managed care will not change that requirement (IDHW, 2026b).

Consider the philosophy embedded in that combination. A person must be poor enough to qualify for Medicaid, remain administratively eligible, comply with applicable reporting requirements, successfully navigate exemptions when necessary, and then participate in cost sharing where applicable. There is an extraordinary amount of energy devoted to making sure that people with very little demonstrate sufficient personal responsibility for having very little.

Who Is Actually Being Asked to Sacrifice

If all of these reductions were part of a genuine program of shared austerity, I would evaluate them differently. Fiscal restraint sometimes requires difficult decisions. Governments cannot spend without limits. Programs can become inefficient. Fraud exists. Waste exists. Taxpayers have every right to expect stewardship.

Shared sacrifice, however, requires the sacrifice to be shared.

The Congressional Budget Office examined how Public Law 119 21 changes household resources across the income distribution after accounting for federal taxes, cash transfers, Medicaid and SNAP, state fiscal responses, and other spending. Its conclusion is difficult to dismiss as partisan rhetoric because it is almost painfully clinical. Resources decrease for households toward the bottom of the income distribution while increasing for households in the middle and toward the top (CBO, 2025a).

The numbers make the contrast clearer. Averaged over 2026 through 2034, CBO estimates that households in the lowest income tenth will lose approximately $1,214 in resources per household each year relative to the January 2025 baseline. Households in the highest income tenth will gain approximately $13,622 annually. For the lowest tenth, that represents a 3.1 percent reduction in resources after taxes and transfers. For the highest tenth, it represents a 2.7 percent increase. The highest income tenth receives 63.9 percent of the total net increase in household resources attributed to the law (CBO, 2025b).

Those changes result from several parts of the law, and CBO specifically identifies federal tax policy, including extensions of provisions from the 2017 tax law, as one channel increasing household resources while decreases in Medicaid and SNAP reduce resources available to participating households (CBO, 2025b).

I am not arguing that wealthy Americans should be punished for being successful. Wealth is not a moral failure any more than poverty is. Lower taxation can be legitimate conservative policy, and there are serious economic arguments for allowing households and businesses to retain more of what they earn.

But there is a rather large elephant sitting in the fiscal responsibility room.

We are telling poor Americans that the federal government cannot afford their current level of health and food assistance while simultaneously enacting a policy package under which the highest income households receive substantial net gains.

That is not shared austerity.

The poorest households are not simply being asked to tighten their belts alongside everyone else. CBO says they lose resources while the highest income households gain them.

That is not a Democratic talking point. It is arithmetic from the Congressional Budget Office.

I support fiscal responsibility. What I reject is defining fiscal responsibility as requiring the greatest scrutiny from the people with the fewest resources while asking considerably less sacrifice from the people most capable of absorbing it.

Fiscal responsibility, apparently, has an income bracket.

Idaho Has Its Own Version

Idaho provides an unusually clear state level example of the same tension.

In March 2025, Governor Brad Little signed House Bill 40, reducing the individual and corporate income tax rate from 5.695 percent to 5.3 percent. The Governor described the legislation as the largest income tax cut in Idaho history and estimated that it would return approximately $253 million to Idaho taxpayers (Office of the Governor of Idaho, 2025).

There is a legitimate conservative argument for that policy. Idaho leaders contend that taxpayers should retain more of their earnings, that lower income and business tax rates improve economic competitiveness, and that government should restrain spending rather than continually demanding more revenue. Those arguments deserve to be represented honestly.

Distribution matters too.

An analysis of the 2025 Idaho income tax package by the Idaho Center for Fiscal Policy estimated that the highest income 20 percent of Idaho households, those earning approximately $146,700 or more, will receive 66 percent of the benefits from House Bill 40. The report estimated an average annual income tax reduction of approximately $5,358 for the highest income 1 percent, compared with approximately $127 for a household earning the median income (Idaho Center for Fiscal Policy [ICFP], 2025).

That is the Idaho comparison I find far more interesting than another argument about whether Republicans or Democrats care more about poor people.

House Bill 40 reduces annual state revenue by approximately $253 million while directing most of its benefits toward the highest income fifth of households. At roughly the same time, Idaho Medicaid policy is moving toward work reporting requirements, six month eligibility checks, broad managed care, and a statutory requirement for cost sharing at the highest level approved by any state.

Again, I am not opposed to tax cuts simply because wealthy people receive them. A flat percentage rate reduction will naturally produce larger dollar savings for someone paying substantially more income tax. That mathematical reality is not evidence of corruption.

It is, however, relevant when government begins talking about scarcity.

If Idaho can choose to relinquish hundreds of millions of dollars in annual revenue, then it is reasonable to ask why greater financial and administrative burdens imposed on poor Idahoans are subsequently framed as unavoidable fiscal necessity. If we have enough room in the budget to prioritize a tax structure in which the highest income households receive most of the benefit, then we should be able to discuss openly why the people with the least financial margin are simultaneously being asked to prove more, report more, comply more frequently, and participate in greater cost sharing.

That is not class warfare.

That is asking to see the receipt.

A broader 2026 Idaho Center for Fiscal Policy analysis reached a similar conclusion across several years of state and federal tax changes. It estimated that 73 percent of the benefits from the combined income tax changes examined went to the highest income 20 percent of Idaho households, while households earning less than $29,200 experienced an average annual tax increase of $96 (Roberts, 2026). Because that analysis combines multiple state and federal policies, it should not be attributed solely to House Bill 40. Keeping those claims separate matters if we expect people to trust the argument.

Fraud Is Real and So Are Eligible People

None of this requires pretending that fraud does not exist. Fraud in public programs should be investigated and prosecuted. Improper payments should be corrected. Eligibility standards should mean something. Government owes taxpayers competent administration.

The intellectually important question is whether a policy identifies fraud or creates friction throughout the entire eligible population.

Those are not synonymous.

If government saves money because an ineligible person is removed from Medicaid, that is program integrity. If government saves the same amount because an eligible person loses Medicaid after missing a renewal notice or failing to document an exemption correctly, the financial statement records reduced spending in both cases.

The public health outcomes are very different.

This distinction becomes even more important when immigration is introduced into the conversation. Arguments over undocumented immigration deserve their own serious policy discussion, but they cannot explain broad reductions to Medicaid, SNAP, and SSI by implying that undocumented immigrants were freely collecting all three programs. Federal eligibility rules already exclude undocumented immigrants from regular federally funded Medicaid, SNAP, and SSI. Broad reductions affecting eligible low income households therefore cannot be reduced to a story about removing undocumented immigrants from programs in which they were already prohibited from participating.

Fiscal conservatism should be capable of distinguishing fraud from poverty, immigration enforcement from disability policy, and administrative efficiency from administrative attrition.

Otherwise we are not measuring integrity.

We are measuring how many people government managed to remove.

The Costs Do Not Disappear

Public health requires us to follow consequences beyond the program where the original budget reduction occurs. Health coverage influences access to medication, preventive care, chronic disease management, emergency treatment, caregiver burden, employment stability, and the ability of disabled people to remain safely in their communities.

When Medicaid spending falls because someone loses coverage, the persons diabetes, epilepsy, heart disease, mobility impairment, psychiatric condition, developmental disability, or chronic illness does not decline proportionally with federal expenditures.

Someone still carries the need.

Sometimes that person goes without treatment until the condition becomes more serious. Sometimes a hospital absorbs uncompensated care. Sometimes a family pays expenses it cannot afford. Sometimes a parent becomes an unpaid caregiver. Sometimes a spouse reduces working hours. Sometimes an adult child leaves the workforce to care for an aging parent. Sometimes a person who might have remained safely at home eventually requires a more restrictive and expensive level of care.

Family caregiving is especially convenient to overlook because unpaid labor looks wonderfully inexpensive on a government spreadsheet.

It is not free.

The cost has simply been transferred from a public budget to a household.

That is why I reject the assumption that every reduction in government spending represents efficiency. Efficiency means accomplishing the same or a better outcome using fewer resources. Cost shifting means someone else receives the bill.

A government capable of basic arithmetic should know the difference.

The People Behind the Savings

Poor and disabled Americans are not budgetary clutter. They are workers, children, parents, caregivers, veterans, neighbors, taxpayers, church members, and human beings whose bodies or circumstances sometimes require more support than our cultural mythology about independence likes to acknowledge.

Some will work full time. Some will work intermittently. Some will never be capable of conventional employment. Some disabled people will need assistance for their entire lives. Human worth has never been synonymous with economic productivity, and a society that begins treating those concepts as interchangeable should be very careful about where that logic eventually leads.

We can believe in work without pretending every body can reliably produce 80 hours every month. We can investigate fraud without creating administrative obstacle courses for eligible people. We can advocate for limited government while acknowledging that unpaid mothers and fathers are already providing enormous amounts of care that government does not have to finance. We can support tax relief while still asking who receives most of it. We can demand fiscal stewardship without pretending that transferring costs from Washington to families constitutes some triumph of economic efficiency.

As a conservative, I do not believe government should become the permanent solution to every human difficulty. As a public health educator, I also cannot pretend that stripping resources from vulnerable populations produces no downstream consequences simply because those consequences appear in another budget, another institution, or another household.

Most importantly, we need to stop saying fiscal responsibility as though the phrase itself settles the argument.

It does not.

The more revealing question is who is being required to practice it.

Right now, the evidence tells an uncomfortable story. Federal policy is reducing Medicaid and SNAP spending while CBO projects losses for households at the bottom and substantial gains for households at the top. Idaho has enacted hundreds of millions of dollars in annual tax relief with benefits heavily concentrated among higher income households while simultaneously moving poor Medicaid recipients toward additional work reporting, more frequent eligibility review, cost sharing, and a transformed managed care system.

You can believe every one of those policies was enacted with good intentions and still ask whether their cumulative effect is just.

You can believe in fiscal conservatism and still demand consistency.

You can believe in personal responsibility without assuming poverty proves a lack of it.

Before we congratulate government for saving money, perhaps we should spend a little more time looking at the people holding the bill.

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