This is a long read the real information comes in the section titled “who wins and who loses”.

By GovFacts20 Mins ReadOctober 2, 2025

Last updated 2 weeks ago. Our resources are updated regularly but please keep in mind that links, programs, policies, and contact information do change.

TrumpRx is a federal government initiative centered around a new website, TrumpRx.gov, slated to launch in early 2026. The primary stated goal is to lower the cost of prescription drugs for Americans by creating a new pathway for purchasing medications directly from manufacturers at discounted rates.

The government-operated website will not directly sell or distribute medications. Instead, it’s designed to function as a search portal. Consumers can use the site to look up their prescriptions and, if a drug is part of the program, they will be redirected to the pharmaceutical manufacturer’s own direct-to-consumer platform to complete the purchase. This portal model keeps the government out of the complex logistics of the pharmaceutical supply chain.

The initiative was launched through a landmark voluntary agreement with pharmaceutical giant Pfizer, which became the first drugmaker to formally commit to the program’s principles. The administration has stated its expectation that other pharmaceutical companies will negotiate similar deals in the future.

TrumpRx is the public-facing component of a broader policy known as “Most-Favored-Nation” (MFN) pricing. This underlying doctrine aims to align the prices Americans pay for brand-name drugs with the lowest prices paid in other developed countries.

The name “TrumpRx” is a political branding strategy, directly tying the initiative’s perceived success or failure to the president. This creates high political stakes and has led some experts to caution that the branding could backfire if U.S. drug prices remain high for most consumers.

The “Most-Favored-Nation” Doctrine

The “Most-Favored-Nation” policy is the central principle that gives the TrumpRx initiative its purpose and structure. In this context, MFN pricing means that the United States should pay no more for a given prescription drug than the lowest price paid among a peer group of other wealthy, developed nations.

This represents a form of external reference pricing, a tool used by many countries to control pharmaceutical costs by benchmarking their prices against those in other markets.

The Reference Countries

The reference price is determined by comparing U.S. prices to those in a specific “basket” of countries. The 2025 announcement specified this group includes the six other G7 countries (Canada, France, Germany, Italy, Japan, and the United Kingdom) as well as Switzerland and Denmark.

The Department of Health and Human Services (HHS) further clarified that the benchmark would be the lowest price in a country that is part of the OECD and has a per capita GDP of at least 60% of the U.S. per capita GDP.

A critical technical detail is that the MFN price is based on a drug’s net price—the final price after all confidential rebates and discounts are applied—not the initial, publicly listed wholesale price. This is intended to create a more accurate comparison with the heavily negotiated prices paid by foreign government health systems.

The “Global Freeloading” Rationale

The administration’s central argument for implementing MFN pricing is to end what it terms “global freeloading”. The theory posits that the United States disproportionately finances global pharmaceutical innovation.

According to this view, other developed nations use their centralized, single-payer health systems to impose artificially low price controls on drugs. This forces pharmaceutical manufacturers to recoup their research and development costs and generate profits by charging significantly higher prices in the less-regulated U.S. system.

President Trump articulated this position directly, stating, “The United States is done subsidizing the health care of the rest of the world”. This framing positions the issue as a matter of international trade fairness rather than purely as a domestic healthcare cost problem, which justifies the use of trade-based leverage, such as tariffs, to achieve policy goals.

Policy History and Legal Precedent

The 2025 announcement of TrumpRx was not the administration’s first attempt to implement an MFN policy. The effort has a complex history rooted in a previous executive order and subsequent legal battles.

The 2020 Executive Order

During his first term, on September 13, 2020, President Trump issued an executive order titled “Lowering Drug Prices by Putting America First”. This order directed HHS to test an MFN payment model for certain drugs covered under Medicare Parts B and D.

To implement the 2020 order, the administration issued an Interim Final Rule (IFR) that bypassed the standard public notice-and-comment period required by the Administrative Procedure Act. The administration claimed it had “good cause” to expedite the rule due to rising drug prices and the economic strains of the COVID-19 pandemic.

This move was immediately challenged in court by pharmaceutical industry groups. Multiple federal courts issued injunctions, blocking the rule from taking effect on the grounds that the administration had not provided sufficient justification for skipping the standard rulemaking process. The rule was ultimately rescinded by the Biden administration in December 2021.

The May 12, 2025 Executive Order

The policy was revived with a new executive order, “Delivering Most-Favored-Nation Prescription Drug Pricing to American Patients”.

Learning from the previous legal defeats, this new order took a different strategic approach. Instead of immediately imposing a rule, it first directed HHS to communicate MFN price targets to manufacturers and called for voluntary compliance.

The order backed this request with the threat of future, more aggressive actions—including formal rulemaking and punitive tariffs—if companies did not make “significant progress” on their own. This represents a strategic pivot from direct regulatory command to a model of coercive negotiation.

The Pfizer Agreement

On September 30, 2025, just ahead of a deadline set by the White House, Pfizer became the first major pharmaceutical company to publicly agree to the administration’s MFN framework. The deal, announced in the Oval Office with President Trump and Pfizer CEO Albert Bourla, is a complex, multi-part agreement that serves as the foundation for the TrumpRx launch.

Key Components of the Deal

MFN Pricing for Medicaid: Pfizer committed to offer its entire portfolio of drugs, including all new medicines it brings to market, to every state Medicaid program at MFN prices. This new pricing structure is scheduled to begin in early 2026.

Direct-to-Consumer Discounts via TrumpRx.gov: Pfizer agreed to offer a “large majority” of its primary care treatments and some specialty brand-name drugs on the TrumpRx.gov platform at significant discounts. According to the company and the White House, these discounts will average 50% off the list price and could be as high as 85% for some medications.

Specific examples provided include an 80% discount for the atopic dermatitis ointment Eucrisa, a 40% discount for the rheumatoid arthritis drug Xeljanz, and a 50% discount for the migraine treatment Zavzpret.

Pfizer’s Quid Pro Quo: Tariff Exemption: The core of the negotiation appears to be a trade-off. In exchange for its voluntary cooperation, Pfizer received a three-year grace period, exempting its products from the administration’s threatened 100% tariff on imported branded pharmaceuticals.

Pfizer’s CEO, Albert Bourla, publicly acknowledged that the tariff threat was a “powerful tool” that motivated the company’s decision to come to the table.

Domestic Investment Pledge: As part of the deal, Pfizer announced a commitment to invest an additional $70 billion in U.S.-based manufacturing, research, and development in the coming years.

This structure suggests the agreement is less a pure healthcare policy and more a strategic negotiation rooted in trade and industrial policy. The drug price concessions can be seen as the cost Pfizer was willing to pay to avoid a potentially more damaging trade penalty and to gain regulatory predictability, which CEO Albert Bourla stated provides “the certainty and stability we need”.

Confidentiality and Unanswered Questions

A significant point of analysis and criticism surrounding the Pfizer deal is its lack of transparency. Both Pfizer and the White House have stated that the specific terms of the agreement, including the precise methodology used to calculate the discounts and the MFN price, remain confidential.

This confidentiality makes it impossible for independent analysts to verify the administration’s claims of savings or for other companies to accurately model a similar agreement. It particularly obscures whether the new MFN price for Medicaid will be substantially lower than the already-discounted “best price” that Medicaid is entitled to under existing federal law.

Provision	Details	Stated Goal / Rationale
MFN for Medicaid	All Pfizer drugs, including new launches, to be offered to state Medicaid programs at the lowest price paid in a basket of peer nations, starting early 2026.	Lower costs for state and federal taxpayers; strengthen Medicaid for the most vulnerable.
TrumpRx.gov Discounts	Select drugs like Eucrisa and Xeljanz offered at 40-85% discounts off list price via a direct-to-consumer platform.	Provide direct savings to cash-paying American consumers by bypassing middlemen.
Tariff Exemption for Pfizer	Pfizer receives a 3-year grace period from the administration’s threatened 100% tariffs on imported branded drugs.	Incentivize voluntary compliance with MFN policy and reward the first mover.
Domestic Investment	Pfizer pledges $70 billion for U.S.-based manufacturing and R&D.	Onshore pharmaceutical manufacturing, create American jobs, and secure domestic supply chains.

How TrumpRx.gov Works for Consumers

The User Journey

The consumer experience on TrumpRx.gov is designed to be straightforward. It will function as a search portal, not an e-commerce website where transactions take place. A consumer would visit the site, search for a specific medication, and if that drug is part of the program, the site would provide information on the discounted price and a link to the manufacturer’s own platform to make the purchase.

The Payment Model: Bypassing Insurance

A defining feature of the TrumpRx model is that all purchases are cash-pay, out-of-pocket transactions. The system is explicitly designed to “bypass middlemen” such as health insurers and Pharmacy Benefit Managers (PBMs), the third-party administrators that manage prescription drug benefits for health plans.

This approach aligns with a broader trend of pharmaceutical companies exploring direct-to-consumer channels to gain more control over pricing and patient relationships.

The Critical Question of Deductibles

For the majority of Americans who have health insurance, a crucial financial consideration is that payments made for drugs purchased through TrumpRx would almost certainly not count toward their health insurance deductibles or annual out-of-pocket maximums.

Health insurance plans typically only credit payments toward these limits when they are for covered services and drugs processed through their approved network of pharmacies and providers.

This creates a potential “two-track” system for drug purchasing that could lead to complex financial trade-offs for consumers. For example, a patient with a high-deductible plan might face a difficult choice: pay a lower immediate cash price for a drug via TrumpRx, or pay a higher price through their insurance to make progress toward meeting their annual deductible.

The latter option could save them more money in the long run if they anticipate significant other healthcare costs during the year. Because TrumpRx purchases exist outside the insurance system, the program could inadvertently increase a patient’s total annual healthcare spending even if it lowers the cost of a single prescription.

Comparison to Existing Platforms

The direct-to-consumer model leveraged by TrumpRx is not entirely new and shares conceptual similarities with private-sector platforms that also operate largely outside the traditional insurance framework. These include:

Discount Card Programs like GoodRx: These services provide consumers with coupons that offer cash-price discounts at traditional retail pharmacies.

See also Court Drama: The Key Differences Between Civil and Criminal Law

Direct-to-Patient Pharmacies like Mark Cuban’s Cost Plus Drugs: This company operates as a registered pharmacy that acquires generic drugs directly from manufacturers and sells them with a transparent, fixed markup, passing the savings to cash-paying consumers.

TrumpRx is distinct from these models because it is a government-branded portal that will feature primarily brand-name drugs from specific manufacturers at prices purportedly based on federally facilitated MFN agreements.

Who Wins, Who Loses, and Who is Unaffected

The practical impact of the TrumpRx initiative and the underlying MFN policy is likely to be unevenly distributed across the American population. The benefits and drawbacks vary significantly depending on an individual’s insurance status and healthcare needs.

Potential Beneficiaries

The Uninsured: This segment stands to benefit the most from the TrumpRx platform. Without any insurance coverage, these individuals currently face the full, undiscounted retail price for prescription drugs and possess little to no negotiating power. TrumpRx offers them a direct pathway to potentially significant discounts on certain brand-name medications, provided they can afford the final cash price.

The Underinsured (High-Deductible Health Plans): Patients enrolled in high-deductible health plans (HDHPs) who have not yet met their annual deductible may also find value in TrumpRx. Before the deductible is met, these patients are responsible for the full, insurer-negotiated price of their drugs. In some cases, the discounted cash price on TrumpRx could be lower than this pre-deductible price.

This is particularly relevant for drugs in therapeutic areas that are often not covered by insurance, such as certain dermatological treatments or medications for weight loss.

Groups with Limited or No Direct Impact

Impact on Government and Taxpayers

The primary financial benefit to the government is expected to come from Pfizer offering MFN prices for its drugs to state Medicaid programs. This could result in significant savings for both state governments and the federal government, which jointly fund Medicaid.

However, the true scale of these savings is difficult to assess. Federal law already requires drug manufacturers to provide Medicaid with substantial rebates, ensuring the program receives the “best price” offered to any other purchaser in the U.S. Without access to the confidential terms of the Pfizer deal, it is unclear how much lower the MFN price will be compared to the already-low prices Medicaid currently pays.

A History of U.S. Drug Pricing Reform Efforts

The TrumpRx initiative and its MFN foundation are part of a long and ongoing debate over how to address the high cost of prescription drugs in the United States. Understanding this context requires comparing the MFN approach to other major reform proposals, both past and present.

Predecessor Policy: The International Pricing Index (IPI) Model

Before reviving the MFN concept, the Trump administration’s first term saw the proposal of the International Pricing Index (IPI) model.

Mechanism: The IPI was envisioned as a mandatory payment model for Medicare Part B, which covers physician-administered drugs like infusions for cancer or rheumatoid arthritis. It would have gradually phased down Medicare’s reimbursement for these drugs to align with an index of prices paid in other developed countries.

A key feature was its plan to replace the traditional “buy and bill” system—where physicians purchase drugs and are then reimbursed by Medicare—with a new model where private-sector vendors would acquire and distribute the drugs, taking on the financial risk.

Status: The IPI was introduced via an Advance Notice of Proposed Rulemaking, soliciting public comment, but it was never finalized into a formal rule. It faced strong opposition from physician groups and the pharmaceutical industry and was eventually superseded by the MFN executive order.

Comparison with the Inflation Reduction Act (IRA) Medicare Negotiation

The Biden administration’s landmark drug pricing reform, enacted through the Inflation Reduction Act (IRA) of 2022, offers a fundamentally different approach to cost control.

Mechanism: The IRA empowers the Secretary of HHS to directly negotiate a “Maximum Fair Price” with manufacturers for a select list of high-cost drugs. This is a process of active negotiation, backed by a severe excise tax for non-compliance, rather than the passive adoption of a foreign reference price as seen in the MFN model.

Scope: The IRA’s negotiation program is narrowly focused. It applies only to a small, gradually expanding list of the highest-spending drugs in Medicare Parts B and D that have been on the market for a specified number of years without generic or biosimilar competition.

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The MFN policy, as articulated in the 2025 executive order, is envisioned to be much broader, calling for MFN prices across all brand products for Medicaid and on all new drug launches.

Legal Basis: The IRA’s negotiation authority was explicitly granted by Congress through legislation, giving it a firm legal foundation. The MFN policy, by contrast, relies on executive authority, which has proven to be on shakier legal ground, as demonstrated by the successful court challenges to the 2020 MFN rule.

Comparison with Drug Importation

Another frequently discussed reform is allowing the safe importation of lower-priced prescription drugs from other countries, particularly Canada. This policy aims to leverage international price differences by allowing U.S. consumers access to foreign markets.

The May 2025 MFN executive order explicitly includes a directive for HHS to consider expanding drug importation programs if pharmaceutical manufacturers do not voluntarily adopt MFN pricing, positioning it as another potential tool of leverage.

Policy Approach	Core Mechanism	Primary Target	Legal/Implementation Status
Most-Favored-Nation (MFN) Pricing	Sets U.S. price based on the lowest net price in a basket of peer nations.	Initially Medicaid and DTC cash-paying consumers; potentially all brand drugs.	Based on Executive Order; one voluntary deal with Pfizer; legal authority for mandatory imposition is questionable.
IRA Medicare Negotiation	Direct negotiation between HHS and manufacturers to set a “Maximum Fair Price.”	Select high-spend, single-source drugs in Medicare Parts D and B.	Enacted into law by Congress; currently being implemented.
International Pricing Index (IPI)	Phased-in price alignment with an international index for Part B drugs.	Medicare Part B physician-administered drugs.	Proposed during first Trump term; never finalized.
Drug Importation	Allows pharmacies and wholesalers to import FDA-approved drugs from other countries.	All prescription drugs, particularly from Canada.	Authorized by law but implementation has been limited due to logistical and regulatory hurdles.

The Debate: Perspectives from Stakeholders and Experts

The announcement of TrumpRx and the MFN policy has ignited a robust debate among key stakeholders, including the administration, the pharmaceutical industry, patient advocates, and independent policy experts.

The Administration’s Case (Proponents)

The Trump administration and its supporters frame the MFN policy as a matter of fundamental fairness. The core argument is that American consumers and taxpayers have for too long been forced to pay exorbitant prices for medicines, effectively subsidizing lower costs for the rest of the developed world.

Officials have characterized the existing system as a “ripoff” and have positioned the TrumpRx initiative as a way to deliver tangible cost savings directly to patients and taxpayers by bypassing what they describe as inefficient and costly middlemen. The administration has claimed the policy will have a “huge impact” on lowering healthcare costs, particularly for the Medicaid program.

The Pharmaceutical Industry’s Position

The pharmaceutical industry has had a bifurcated response, with Pfizer participating in the program while the broader industry lobby remains opposed.

Pfizer’s Stance: CEO Albert Bourla has publicly presented the deal as a “win-win.” He argued that the agreement provides his company with crucial “certainty and stability” on two major fronts: future drug pricing and the threat of punitive tariffs. By making a voluntary deal, Pfizer avoids the risk of potentially harsher, mandatory price controls and damaging trade penalties.

Broader Industry (PhRMA): The Pharmaceutical Research and Manufacturers of America (PhRMA), the industry’s main lobbying group, is staunchly opposed to the MFN concept. PhRMA has characterized the policy as the importation of “foreign price controls” from “socialist countries”. The group argues that such policies will stifle innovation, drastically reduce investment in R&D, lead to fewer new cures, and ultimately harm patient access to the next generation of medicines.

PhRMA consistently deflects blame for high U.S. prices onto other parts of the supply chain, particularly PBMs and alleged abuses in the 340B hospital discount program.

Patient Advocacy Groups (Supporters)

AARP: The influential seniors’ advocacy group has praised the MFN executive order. AARP thanked the administration for “standing up to the big drug companies to disrupt the status quo”. Their support is rooted in the belief that high drug costs force seniors to make impossible choices between affording life-saving medications and paying for other necessities like food.

Independent Policy Analysis (Skeptics)

Many independent health economists and policy experts have expressed significant skepticism about the TrumpRx initiative.

Limited Impact: A common critique is that the program is a “gimmick” or “window dressing” that will have “little to no effect” for the vast majority of consumers who are already insured.

Lack of Substance: Critics point to the confidential terms of the Pfizer deal, the small number of drugs initially included, and the fact that even heavily discounted prices for expensive specialty drugs remain unaffordably high for cash-paying patients as evidence that the program is more “pomp and circumstance” than substantive reform.

Potential Negative Consequences: Some conservative and market-oriented think tanks, such as the American Action Forum, have argued that imposing MFN pricing across Medicare Part D would be its “death knell”. They contend it would destroy the market-based negotiation structure that has successfully controlled costs in the program, effectively turning it into a restrictive, government-run, single-payer system with diminished access to medicines.

Stakeholder	Position	Key Argument	Primary Concern
The Trump Administration	Strongly Supportive	Ends “global freeloading” and brings fairness and lower prices to U.S. patients.	High drug prices are politically unpopular and economically unsustainable for consumers and government programs.
Pfizer	Cooperative Participant	Provides regulatory certainty on pricing and avoids punitive tariffs, which is good for business stability.	An unpredictable regulatory environment and the financial impact of tariffs.
PhRMA (Industry)	Strongly Opposed	MFN is a form of government price control that will stifle innovation, reduce R&D, and harm patient access.	Loss of revenue, reduced ability to fund R&D for new medicines, and government overreach into the market.
AARP (Patient Advocates)	Supportive	A necessary action to control exorbitant drug prices that harm seniors.	Members’ inability to afford life-saving medications due to high out-of-pocket costs.
Independent Policy Analysts	Skeptical	The program’s scope is too limited to affect most Americans; lacks transparency and may be more political than substantive.	Policy may be more political theater than effective reform; could have unintended financial consequences for patients.

Frequently Asked Questions

Is TrumpRx a pharmacy?

No. TrumpRx.gov is a government-run website that will function as a search portal. It will not sell, dispense, or ship medicine. Its purpose is to direct consumers to the drug manufacturer’s own website, where a direct purchase can be made.

How is TrumpRx different from GoodRx or Mark Cuban’s Cost Plus Drugs?

While all three aim to lower out-of-pocket drug costs, they operate differently. GoodRx is a private company that provides consumers with discount coupons that can be used at traditional retail pharmacies. Mark Cuban’s Cost Plus Drugs is a licensed mail-order pharmacy that acquires primarily generic drugs and sells them to consumers with a transparent, fixed markup. TrumpRx is a government-operated portal for purchasing brand-name drugs directly from specific manufacturers at prices based on the federally-driven “Most-Favored-Nation” principle.

Will my insurance cover drugs bought through TrumpRx?

No. Purchases made through the TrumpRx pathway are cash-pay transactions that bypass your insurance coverage. The money you spend will almost certainly not count toward your annual insurance deductible or your out-of-pocket maximum.

Which drugs are available on TrumpRx?

Initially, the program will launch with a selection of drugs from Pfizer. The administration has specifically mentioned discounts on medications such as Eucrisa (for atopic dermatitis), Xeljanz (for rheumatoid arthritis), and Zavzpret (for migraines), among others. The administration has stated its intention to negotiate similar agreements with other drug manufacturers to expand the list of available drugs in the future.

When does the TrumpRx program start?

The TrumpRx.gov website and the associated discounted pricing are scheduled to go live in early 2026.

Our articles make government information more accessible. Please consult a qualified professional for financial, legal, or health advice specific to your circumstances.

Author

No, Democrats aren’t trying to fund health care for “illegal aliens.”

Jonathan Cohn

Sep 30

Hey, guys. Earlier today, my colleague Mona Charen and I talked about President Trump’s speech before the generals and admirals, as well as the politics of the government-shutdown fight.

In today’s newsletter, I write about the likely shutdown and the main argument about health care that Trump and his allies are making. I am calling it a “lie,” which is not a phrase I typically use. I reserve it for instances when a claim seems fundamentally untrue and when the people making the claim know better—or, at least, should know better. I think this instance qualifies. Let me know in the comments if you agree.

THE REPUBLICAN PARTY’S CLOSING ARGUMENT heading into the government shutdown is a big, brazen lie.

The lie is so big and so brazen that it’s almost not worth addressing, because doing so gives the claim far more credibility than it deserves.

But it’s become ubiquitous in Republican talking points, from the president on down. There’s also a chance some people will believe it, because it feeds into some common misconceptions about health care and immigration policy, as well as preconceptions of how the parties operate. And in a standoff that has been all about political leverage and public opinion, setting the record straight matters.

So let’s get to it.The claim is about what Democrats are demanding in exchange for their support on a spending bill that would keep the government open past midnight tonight, when funding runs out. Remember, Republicans control both the White House and Congress, but need Democratic votes in the Senate to approve a new spending measure.

The central Democratic demand is about health care: They want Republicans to extend a temporary Biden-era program that has lowered health insurance costs for more than 20 million Americans buying coverage through the Affordable Care Act. And they want Republicans to undo at least some of the dramatic Medicaid cuts that the GOP enacted over the summer, as part of Donald Trump’s “One Big Beautiful Bill.”

Trump and Republican leaders have refused to negotiate. And after flailing about with a few different arguments—including a preposterous claim that Democrats just want to pad the profits of insurance companies—they have settled on a new line: that Democrats want to fund health care for “illegal aliens.”

I put the phrase in quotes because it’s the phrase Republican officials have used over and over again—literally eight times by Vice President JD Vance in one recent Fox News interview, as my Bulwark colleague Will Saletan observed the other day.

Vance made the claim yet again on Monday while standing outside the White House, following a failed negotiation session between GOP and Democratic leaders. At his side was House Speaker Mike Johnson, who’s been putting out the same message, including in a Sunday tweet saying that Democrats “want to give free health care to ILLEGAL ALIENS paid by hardworking Americans.”

And then there is Trump, who has been using the same line in conversations with reporters and on his own social media feeds. On Monday night, he even reposted an AI fake of a press appearance by the Democratic congressional leaders in which the fake Sen. Chuck Schumer says: “If we give all these illegal aliens free health care, we might be able to get them on our side so they can vote for us.” A digitally animated, sombrero-wearing, mustachioed Rep. Hakeem Jeffries looks on as mariachi music plays in the background.

If you’re not too busy gasping at what it says about the president’s state of mind that he’d post this, you might be wondering what on earth he and the Republicans are talking about when they claim Democrats want to fund health care for illegal aliens.

It’s a very good question, because people who are in the United States unlawfully cannot get federally funded health insurance. They cannot sign up for Medicaid. They cannot get federally subsidized coverage through the Affordable Care Act’s online marketplaces.

In other words, what Trump, Vance and the other Republicans are saying is just not true.

SO WHAT COULD THEY HAVE IN MIND with this claim?

It’s hard to be sure, because neither the White House nor Johnson’s office has put out material to substantiate their arguments, or responded to my queries asking for evidence. And when a reporter finally asked the president about it, during a press appearance in the Oval Office on Tuesday, Trump gave a rambling non-response that quickly veered into other immigration-related topics.

In the same press appearance, he said of the Democrats “they want to give incredible Medicare—the Cadillac Medicare—to illegal immigrants.” That’s also not true, in case you were wondering.

As best as I can tell, the Republicans who actually know what they are talking about are zeroing in on a small portion of federal health spending that’s in play as part of the shutdown debate. It’s funding connected either to the Affordable Care Act subsidies Democrats want to extend or to the GOP Medicaid cuts they want to roll back. And they are leaning heavily on a set of two flimsy assertions that appeared in an early September GOP press release and echo claims made by the Paragon Health Institute, an influential conservative think tank.

One of those assertions is about rules that opened up “Obamacare” subsidies to a small number of non-citizens, including some who are in the country because they have protected status. Republicans might not want these people to be eligible for those subsidies. But these people are not “illegal aliens.” They have permission to be in the United States.

The other main assertion is that people here unlawfully are tricking the system, and getting coverage even though they are not eligible. It’s an extension of another highly questionable argument Republicans have made repeatedly over the past few months, which is that many millions of people have been signing up for either Medicaid or subsidized Affordable Care Act insurance fraudulently.

The evidence for that claim is awfully shaky, for reasons you can read here and here and here and here. But even if it were true that millions of Americans were getting Affordable Care Act insurance through deception or error, there’s no reason to think that large numbers of undocumented immigrants would be among them.

For one thing, enrollment systems check citizenship status pretty carefully, by cross-referencing Social Security numbers with data from the Department of Homeland Security. People who apply as non-citizens—say, because they have protected status—must supply other forms of documentation to prove that they have permission to be here and that they qualify for one of the special exemptions allowing them to get coverage.¹

The system isn’t foolproof; no system is. Maybe some undocumented immigrants are going to the trouble of faking data, and maybe DHS is missing them. But most people in the United States unlawfully steer clear of government programs, precisely because they fear triggering deportation for themselves or loved ones.

“People who are immigrants are afraid, they’re not going to risk exposure,” Shelby Gonzales, vice president for immigration policy at the Center on Budget and Policy Priorities, told me in a phone interview. “We’ve got problems getting people who are fully eligible, people who have been eligible for a long time, to trust that they can provide their information.”

That last part is well known to researchers and analysts. Immigrants legally eligible for federally funded benefit programs like Medicaid are actually less likely to get them than U.S. citizens. And during the first Trump administration, immigrants repeatedly told pollsters and journalists they were afraid to seek out public services—or even, in some cases, basic health care.

IF YOU REALLY WANT to give Vance and the Republicans the benefit of the doubt in a way they never do for their political adversaries—if you want to consider the most defensible part of their claim, for the sake of intellectual honesty—you could zero in on a single provision of the One Big Beautiful Bill (OBBB).

It’s a cut tied to a program called “Emergency Medicaid.”

Emergency Medicaid reimburses hospitals for emergency care they provide to immigrants not entitled to federally funded insurance. This includes people who are here lawfully but not eligible for federal programs. It also includes undocumented immigrants.

The OBBB reduces the federal contribution to Emergency Medicaid, saving about $28 billion in federal spending over ten years. If you squint hard enough, you could argue this is an example of the Republicans cutting funds that had been paying for health care of undocumented immigrants—and that Democrats want to restore that money, insofar as they have said they want to undo the legislation’s Medicaid cuts.

But here are a few other things to keep in mind:

That $28 billion over ten years represents less than 3 percent of the health care cuts within the OBBB and less than 1 percent of total Medicaid spending, according to data from the Urban Institute and KFF.

Only a portion of that money actually finances care for undocumented immigrants. Some of it finances care for people here legally but not yet eligible for Medicaid. An example would be people with work permits and those seeking permanent residency, who by law must wait five years before enrolling in Medicaid.

Emergency Medicaid doesn’t go to individuals. It’s a direct subsidy to hospitals and (in some states) outpatient providers, for care they provide.

A lot of the money is spent on truly emergency services like resuscitating somebody from a heart attack or delivering a baby that hospitals and clinics are obligated to provide, thanks to a 1980s law, signed by Ronald Reagan, that prohibits denying care to people who need stabilizing or life-saving treatment.

One other thing to note is that the cut does not apply to Florida, Texas, and eight other states that have refused to expand Medicaid as part of the Affordable Care Act. So this is a cut that largely spares some of the biggest red states, which could be a byproduct of GOP philosophical priorities lining up with those states’ choices, GOP leaders wanting to protect politically friendly states, or both.

As Georgetown research professor Edwin Park told me: “Emergency Medicaid is about reimbursing providers, especially hospitals, and the Emergency Medicaid provision is actually more about further increasing the cost-shifts to expansion states by lowering the match for Emergency Medicaid reimbursements.”

Add it all up, and even the most expansive, generous reading of the Emergency Medicaid argument wouldn’t come close to validating claims by Trump, Vance, and the other GOP leaders.

“Republican talking points have consistently featured claims that Democrats are trying to provide health care to undocumented immigrants, but this debate isn’t about that,” Larry Levitt, executive vice president for health policy at KFF, told me. “Democrats are looking to restore health coverage for citizens and lawfully present immigrants. It is those groups that will bear the brunt of cuts to Medicaid and the ACA.”

To be perfectly clear: Not a single Democrat has talked about wanting to fund care for people in the United States unlawfully. Instead, what Democrats have said is they want to undo Medicaid cuts projected to leave nearly 10 million Americans uninsured—and extend a temporary Biden-era initiative in order to avoid a jump in health insurance premiums expected to affect 20 million more.

You might agree with that. Or not. You might think tying this to the shutdown makes sense. Or not. But you can say one thing about Democrats’ underlying claims that you definitely can’t say about the Republican counterpart: They are telling the truth. The challenges of setting up that verification in real-time was one of the reasons the Obama administration had such a hard time setting up the HealthCare.gov website—and why its rollout in late 2013 was such an infamous