Those who favor block grants or per-capita caps on healthcare spending claim that Medicaid—in its current form—is more wasteful than other parts of the health-care system, and that the AHCA is about making the system more efficient. Yet the facts suggest just the opposite: On virtually every measure, Medicaid is far more efficient than any other part of the American system. A study from the Kaiser Family Foundation found that, after adjusting for differences in health status, Medicaid costs 22 percent less per adult beneficiary than does private insurance. And its growth rates have also shown an effective use of funds. From 2000 to 2015, while private-sector health spending had inflation-adjusted growth of 3.8 percent per enrollee (and Medicare grew at a rate of 2.13 percent) Medicaid had zero real spending growth per enrollee over this 15-year period, including an actually negative real growth rate per enrollee over the last 10 years. Moreover, the Affordable Care Act (ACA), which I advised on throughout my years on the Obama economic team from 2009 to 2014, included strong anti-fraud and program-integrity provisions—including better screening and compliance protocols, as well as new penalties—which push back against the myth that program administrators do not have the tools to target waste and abuse.

So, it’s misleading to suggest that Medicaid should be targeted because it’s inefficient. A likelier motivation is that while Medicare and Social Security have more funding and thus are larger spending-cut targets for supply-siders, many Republicans (perhaps including Donald Trump) fear a middle-class backlash if either of those programs are tinkered with. But many Republicans seem to believe they can mislead middle-class families into believing that Medicaid is only for the poor, and cuts to it would not impact them. Perhaps that is why Donald Trump pledged during the campaign that he would not cut Medicaid, Social Security and Medicare, while he now pledges only to protect the latter two.

Yet those making such a cynical calculation might come to regret it. First, there has already been significant backlash against pulling back from the Medicaid expansion included in the Affordable Care Act. Second, even beyond that expansion, Medicaid is a lifeline for about 70 million Americans—a little more than 20 percent of the population—many of whom rely on it for long-term health services. For instance, nearly two-thirds of all Americans in nursing homes are covered by Medicaid. And Medicaid covers 44 percent of all children with special health-care needs, as well as half of all women with serious disabilities. Third, the program has made care more equitable for children: Under Medicaid, over 40 million children are eligible for guaranteed comprehensive health coverage—including access to physical and mental-health therapies, dental and vision care, and medical equipment—so that childhood health conditions can be discovered and treated before they become serious or disabling. And finally, many, many Americans care deeply about the hardship such Medicaid cuts would bring to their country’s poorest citizens.