- 宏觀策略師
香港, 個人投資者
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本刊所載見解反映作者於撰文時的觀點，其他團隊可能觀點各異，或會作出不同的投資決策。閣下投資的價值可能高於或低於初始投資時的水平。本刊所載第三方數據被視為可靠，惟概不保證其準確性。
宏觀策略師 Juhi Dhawan 研究了美國龐大的醫療補助計劃變化對經濟成長、就業、通貨膨脹及金融市場可能產生的影響。 (僅提供英文版)
In the coming months, I'll be sharing a series of insights on the Trump administration's efforts to downsize the government and what they could mean for the economy, industry, and markets. After examining the effects of deregulation, I turn my attention to the potential impact of changes in Medicaid, a program that has grown significantly over the years.
In 2024, 0.6% of the 2.8% growth in the US economy was a result of government spending (0.2% at the federal level and 0.4% at the state/local level). Health care, which accounts for 17.5% of the US economy, was a strong contributor to that government-driven growth. With this in mind, it's important to understand what's at stake as the Trump administration considers Medicaid changes and spending cuts, including the implications for economic growth, employment, inflation, and financial markets.
Why Medicaid matters so much
Since the passage of the American Care Act (ACA) in 2010, Medicaid enrollment has grown by nearly 35 million people, helping to reduce the uninsured population by almost 45% (Figure 1). The rise in coverage and the increased utilization by enrollees have contributed to robust growth in US health care spending recently — more than twice the rate of nominal growth in the US economy as of the third quarter of 2024.
Figure 1
Since early 2023, when the Biden administration ended the "continuous enrollment" provision that had been put in place during the pandemic, Medicaid enrollment has been under some downward pressure (as shown in Figure 1), with roughly 15 million people removed from the rolls, according to the Kaiser Family Foundation. The most recent strength in health care spending has thus come more from a pick-up in "marketplace" enrollment (state-level organizations through which health insurance can be purchased) and private insurance usage post-COVID. Still, the expansion of Medicaid has made the US government the biggest sponsor of health care expenditures (exceeding households, private businesses, and state and local governments) and, therefore, a target for possible cost cutting as the government budget deficit is in focus.
What Medicaid changes could mean for the economy
Republicans have put forward several proposals for spending reductions to help fund tax-cut extensions, and Medicaid changes appear to be on the table. It remains to be seen how far the party is willing to go, given the importance of the issue to constituents, memories of the failed effort to repeal the ACA in 2017, and the potential for a challenging midterm election down the road.
But if Medicaid cuts are enacted, there will be spillover effects on various areas of the US economy:
State budgets — The Medicaid program is administered by the states, which rely heavily on grants from the federal government to cover the cost. In fact, health-related grants account for about 60% of all transfers made by the federal government to the states. In turn, states allocate only about 15% of their own spending to health care, allowing them to spend far more on education and other needs. So, federal Medicaid cutbacks, should they pass, will force states with balanced-budget mandates to either raise taxes, cut spending on Medicaid, or cut spending elsewhere — in other words, there will be trade-offs, with implications for states' economic well-being. Of course, there is also a human angle to these difficult decisions and the resulting trade-offs when it comes to equity in health care coverage. Some states may opt to reduce benefits, for example, while others may choose to reduce the number of residents who qualify for coverage.
Employment — The surge in health care spending has brought big gains for the US labor market, with government and private health care jobs collectively accounting for roughly two-thirds of the gains in each of the last two years (Figure 2). These gains helped support labor incomes and carried the US economy during a period in which parts of the private sector struggled. If health care jobs slow meaningfully at a time when government is also cutting back elsewhere, it could weigh on the broader economy and contribute to a downturn unless the private sector picks up the slack.
Figure 2
Inflation — A distinct feature of the last decade has been less upward pressure on health care prices relative to the broader inflation rate. This is a result of efforts in the health care sector to cut costs, focus on outcomes, and take more of a value approach, and it has helped to restrain inflation more broadly, as shown in Figure 3. Notably, despite an aging population, the share of health care in the US economy has been roughly stable over the past 15 years (excluding the COVID surge). Of course, the cost of health care in the US far outstrips global peers and the need to narrow this difference will only grow over time as the demographic pressures on health care rise and add to the cost of Medicare and Medicaid, which together account for more than a quarter of government outlays.
Figure 3
A challenging political path
I expect a protracted political process. Currently, my base case is that the Republicans will eventually push through some of the spending cuts described in the current proposals but not all of them. Given the party's slim majorities in Congress, it will be difficult to drum up the support needed to make the more drastic changes in Medicaid being considered. It is also the case that the recent Medicaid expansion discussed earlier has benefited many Republican states, making some of the proposals controversial even within the president's own party. I would note too that the final budget outcome may depend to some extent, as it often does, on the overall condition of the economy when lawmakers are preparing to vote.
Implications for financial markets
Financial markets are increasingly focused on the size of the US budget deficit, with bond investors beginning to demand a higher term premium to own longer-term US Treasuries. Modest Medicaid cutbacks would allow the Republican party to extend expiring tax cuts but also demonstrate an ability to curb spending. On the other hand, failure to achieve some spending control (whether in Medicaid or other areas) would damage US creditworthiness, while severe spending cuts would risk an economic downturn. Health care's impact on both employment and prices (Figures 2 and 3) also means that the Federal Reserve will be watching these developments closely as it determines its future course of action.
From an equity market perspective, it is worth noting that the health care sector's equity earnings are far outpacing the sector's market-cap contribution (Figure 4). Successful resolution of some of these spending and budget deficit issues may serve to lift the overhang on this sector.
Figure 4
Final thoughts on the medium-term outlook
Looking out over the medium term, health care is likely to remain a contentious area in US politics given its growing role in the US deficit and the country's demographic pressures, which will continue to drive strong demand. Efficiency gains and innovation that improves productivity in a traditionally labor-intensive sector will increasingly matter for sector profitability under this heightened scrutiny.
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