How Trump broke the politics of Medicaid

Politico

3 days ago

Republicans used to cheer the possibility of Medicaid cuts. Now, as the GOP advances President Donald Trump's 'Big Beautiful Bill' that would reduce Medicaid spending, they're rebranding it as making the program stronger.
The shift reflects the striking new politics of Medicaid — and how dramatically the GOP's coalition has changed under Trump. Now Democrats are hoping Medicaid could be the issue that exposes the cracks in the Trump coalition.
They have seized on a nonpartisan Congressional Budget Office estimate that the bill would cause 7.8 million people to lose access to the low-income health insurance program. At stake is whether Democrats can start to win back working-class voters who have shifted toward the GOP over the past decade.
Medicaid provides health insurance for nearly 80 million people but was long the electoral forgotten sibling of Social Security and Medicare. It's clear in the ads: TV ads for House and Senate races last election cycle were 26 times as likely to mention Medicare, the health care program for seniors, as Medicaid, according to a POLITICO analysis of transcripts from AdImpact, which tracks political advertising. But that's already changing.
'I saw elections 16 years ago where people ran on cutting Medicaid, and there were folks who were on Medicaid who were in the crowd cheering them on,' said Kentucky Gov. Andy Beshear, a potential Democratic candidate for president in 2028. 'That's not the case of where we are today.'
The Medicaid provisions in the GOP's budget bill have prompted new debate even among Republicans. To Beshear and others, that provides an opening. Democrats, he said, should stand in front of hospitals and 'talk about how important Medicaid is,' he said, while emphasizing 'the impact on specific communities.'
Congressional Democrats have seized on the issue, with moderates and progressives alike speaking in defense of the program. The party's House campaign arm is prioritizing Medicaid in swing-district messaging. And TV ads mentioning Medicaid have already run in more Republican-held districts this year than they did all of last cycle.
Republicans are cautious, with an ideologically diverse group of senators wary of cuts and poised to exert significant influence over the bill. Sen. Josh Hawley (R-Mo.), who warned that cutting the program would be 'both morally wrong and politically suicidal,' said last week that Trump had promised him no cuts to benefits.
GOP lawmakers have largely rallied around Trump's bill by arguing the House legislation protects Medicaid by only removing people who do not deserve it in the first place. That careful messaging is a stark difference from a decade ago, when congressional Republicans explicitly prioritized cutting Medicaid and governors blocked its expansion.
One reason for the turnaround: A series of red states expanded Medicaid by ballot initiative between 2017 and 2020 — largely with backing of Democratic-aligned groups — and GOP voters defied their state and local political leaders in large numbers to support the program. Nationwide, enrollment for Medicaid and the Children's Health Insurance Program rose from just shy of 70 million in 2014 to nearly 79 million at the end of 2024.
And at the same time more people were entering the program, including Republican voters in red states, an electoral realignment was shifting working-class voters toward Trump.
'Medicaid has a broader and broader appeal the more people that are on it, and the more people who know someone who's on it. That's incredibly powerful politically,' said Kelly Hall, executive director of the Fairness Project, which backed state Medicaid referendums.
The makeup of Medicaid users was changing — and so were its politics.
For a long time, the program has been relatively absent from federal races. Even in the 2018 midterms, when defending the Affordable Care Act was central to Democrats' midterm messaging, only 30 TV ads across all congressional elections mentioned Medicaid, while nearly 500 mentioned Medicare, POLITICO's analysis found.
But Medicaid expansion was a major issue in many gubernatorial and state legislative races in the 2010s. The success of ballot measures proved the program had a strong constituency, even in red states.
And Trump's popularity with working-class voters also reshaped the GOP's coalition. Compared to Republican candidates before him, Trump's 2024 gains were strongest in counties with high Medicaid enrollment, a POLITICO analysis found. In the 2024 election, 49 percent of Medicaid recipients voted for Trump compared to 47 percent for Kamala Harris, according to Morning Consult polling.
That means cuts to Medicaid or reductions in eligibility could now pose a political risk for Republicans. People who could lose benefits would not just be Democratic voters in blue states, but Republicans in red states and swing districts who supported Trump last year.
Drew Kent, a GOP strategist whose firm recently polled Pennsylvania's voters, found a slight majority, including 30 percent of Republicans, disapproved of work requirements for Medicaid.
'These results are definitely a bit surprising to me,' Kent said. 'It clearly shows the challenges and importance, particularly in a political swing state like Pennsylvania, of getting the policy, messaging, and communications right on an issue of this magnitude.'
Republicans are aware of the potential political liability: The GOP's argument about the bill, which could still face changes in the Senate, is that the changes to the program do not amount to cuts for voters.
'The President wants to preserve and protect Medicaid for the Americans who this program was intended for,' White House Press Secretary Karoline Leavitt said at a press briefing last month. 'We want to see able-bodied Americans at least working 20 hours per week, whether that's part-time or full-time, whether that's even looking for work or volunteering for 20 hours a week, if they are receiving Medicaid.'
A memo from the National Republican Campaign Committee last month advised the party to go on offense, saying the bill protects Medicaid by 'removing illegal immigrants and eliminating fraud.' Among its provisions, the bill would penalize states such as California that use state dollars to extend Medicaid benefits to undocumented immigrants. According to CBO estimates, of the nearly 11 million people who would lose Medicaid or other health insurance due to the bill, about 1.4 million are immigrants.
GOP strategist Josh Novotney argued that approach is in line with what Trump's working-class base wants.
'Most blue-collar Trump supporters I have met or spoken with in large groups do not want their hard-earned taxes going to other people, whether that is student debt forgiveness or Medicaid abuse,' he said. 'That is not at odds with his supporters.'
A Kaiser Family Foundation poll released Friday found a plurality of Republicans, 42 percent, believed the Trump administration's policies would strengthen Medicaid, with only 22 percent believing the program would be weakened. But Republican Medicaid enrollees were more split, with 35 believing Trump would strengthen the program and 34 percent saying he would weaken it.
That is where Democrats see an opening. A nonprofit affiliated with Democrats' House campaign arm is already targeting swing-district Republicans with digital ads accusing members of cutting Medicaid to pay for tax breaks for the rich. And a flurry of other liberal groups have purchased TV or digital ads and planned billboards and other activist campaigns.
'To the extent that this is becoming a bigger political issue, it's simply because their efforts to destroy Medicaid are fundamentally more dangerous and more real than ever before,' said Sen. Chris Murphy (D-Conn.), whose PAC is helping fund a group that opposes Medicaid cuts.
As the bill currently stands, the Medicaid work requirements would not go into effect until the end of 2026. That means Democrats largely won't be able to point during their midterm campaigns to people who have already lost access to Medicaid.
Instead, they may rely on voter trust on an issue that has historically worked for them. While polls have found voters consistently prefer the GOP more on issues such as the economy and immigration — which helped propel Trump's win last year — health care has remained a rare bright spot for Democrats.
'If there is a debate or chaos or uncertainty about Medicaid cuts, then I think Democrats stand to benefit from that because of the brand advantage on health care,' said Democratic pollster Zac McCrary. 'One of the few places where we have maintained an edge.'