The vote was no pandemic fluke. Similar ballot measures in Maine (2017); Idaho, Nebraska and Utah (2018); and Oklahoma (2020) showed the same thing: When given the choice, strong majorities of voters in even the most conservative parts of the nation back expanding Medicaid. Republicans leaders rail against socialism; their constituents embrace a popular social program.
This disconnect goes well beyond Medicaid. Whether it’s support for expanded health care, tougher treatment of corporations or higher taxes on the rich, Republican elites aren’t able to contain the tide of support for economically populist governance within their own party. Donald Trump’s 2016 rhetoric tapped into this latent support — while also fomenting the racial backlash so often used to distract voters from the party’s anti-worker policies. Yet once in office, Trump backstopped congressional Republicans’ agenda of skewed tax cuts and repeal of the Affordable Care Act, while using his executive authority to sabotage both Medicaid and the ACA.
Now Republican elites are caught in a vise of their own making. They’ve aligned with powerful groups and billionaire donors demanding what their own voters are increasingly unwilling to back. If this disconnect doesn’t break American democracy — a real threat, given the party’s increasing reliance on vote rigging to hold power — it will break the current GOP. The only questions are how, and how badly, and what the party will look like after the rupture occurs.
Republicans were not always so hostile to Medicaid. The program actually began as a conservative effort to head off national health insurance. During the Eisenhower administration, House Ways and Means Committee Chairman Wilbur Mills (D-Ark.) crafted a law that encouraged states to set up medical programs for the older poor. It passed with just 23 dissenting votes in the House and two in the Senate.
In 1965, Mills would turn this program into Medicaid. His goal — successful for almost half a century — was to “build a fence” around Medicare and Medicaid, ensuring that public coverage was reserved for those who couldn’t obtain or afford health care at work.
Mills’s approach was similar to the one Republicans had defended since the New Deal. First, the safety net should be for the truly disadvantaged, not the middle class. Second, the states should have a large role in running these programs even if the federal government helped finance them. It was a principle that not just Southern Democrats (who, of course, wanted states to be able to discriminate against Black Americans) but also many Republicans embraced, on the grounds that state governance was closer to the people.
With those restrictions in place, Republicans learned to live with Medicaid. Indeed, Ronald Reagan tried to federalize the program (in return for shifting other anti-poverty programs to the states), and he and George H.W. Bush repeatedly backed budgets that expanded it.
The Republican rapprochement ended in the 1990s, when Rep. Newt Gingrich (Ga.) became the first Republican speaker of the House in 40 years. Though Gingrich demonized Medicaid as “welfare,” the deeper source of his opposition was fiscal: Cutting Medicaid was a way to both balance the budget and slash taxes on corporations and the affluent. His proposed Medicaid cuts led to the fight with Bill Clinton that shut down the government twice in the mid-1990s.
Gingrich lost that battle but won the war to define what his party stood for on health care. For the next quarter-century, Republicans would call for Medicaid “block grants” — a fixed amount for states that would rise much more slowly than projected spending. By the time the ACA passed, with its federal Medicaid expansion (which the Supreme Court majority in 2012 said had to remain optional), conservative support for Medicaid was a distant memory.
The ACA supercharged Republican opposition. The apocalyptic rhetoric — “The fight over Medicaid expansion is a microcosm of this president’s push toward centralized government control,” warned Louisiana Gov. Bobby Jindal (R) in 2013 — belied the reality that the ACA did not radically remake the program. Although it increased the eligibility threshold to roughly 1.4 times the poverty level, it also covered all or virtually all of the initial costs (and 90 percent in perpetuity) and allowed states wide latitude in what they could do to meet the new goal.
Republicans’ opposition belied another reality: Their voters were relying on Medicaid more and more. In rural areas ravaged by the opioid epidemic, and aging communities wracked by deindustrialization, Medicaid was a lifeline. In 2015, 43 percent of Republicans said they or their kids were covered by Medicaid or had been. The figure for Democrats was 40 percent.
GOP voters also said they liked Medicaid. In 2019, nearly 3 in 4 had a favorable view of the program, 6 in 10 said it was working well (the same share as among Democrats), and more than half saw it as a health program, not “welfare.” When GOP politicians attack Medicaid expansion as helping the “able-bodied” rather than “the truly needy” — as Maine’s Republican governor put it before vetoing the Medicaid expansion 60 percent of his state’s voters backed — they’re not just flouting the majority of voters; they’re flouting the majority of their own base.
So, too, with other domestic policies. Republican voters may say they’re against “Obamacare,” but they support many of its key provisions, including the ban on insurers discriminating because of preexisting conditions. Yet 183 House Republicans voted against a 2019 bill to prevent the Trump administration from allowing states to undermine this prohibition (it died in the Senate). Amid a pandemic, the administration continues to back a federal lawsuit that could eliminate the ACA entirely, with hardly a peep of dissent from Republican leaders. The lawsuit stems from changes to the ACA made by 2017 GOP tax cuts — another law so unpopular Republicans haven’t even tried to talk about it on the campaign trail. Discussion of the Republican effort to undo the ACA has been revealingly absent from this week’s convention as well.
Whose views, then, are Republicans representing? A national survey of more than 50,000 Americans conducted by academic researchers in 2012 provides a clue. At the time, the big priorities for congressional Republicans were embodied in Rep. Paul D. Ryan’s (R-Wis.) budget plan — which, surprise, block-granted Medicaid, repealed the ACA, and cut taxes for the rich and corporations.
Ryan’s plan polled terribly, with just 19 percent of Americans backing it. But here’s the more surprising fact: In a year in which former Republican governor Mitt Romney would run alongside Ryan, only 32 percent of Republicans supported the Ryan plan. Even among GOP donors, support fell short of a majority. The only polled group that was more likely to support the Ryan budget than not was party donors with annual incomes above $250,000.
Of course, the biggest GOP donors and the powerful organizations that embody their priorities — from Charles Koch’s Americans for Prosperity to the U.S. Chamber of Commerce — don’t show up in surveys. But we know where they stand. These groups have proved critical to the unified resistance of Republican elites to Medicaid expansion, which Americans for Prosperity claimed would “hurt the very communities it was designed to help.” Even when local business leaders and health providers have backed expansion, conservative organizations have convinced most Republicans to oppose it.
But now the dominoes are falling. With Missouri’s shift into the expansion column, only a dozen states have failed to expand Medicaid. Even before covid-19 made health care issue No. 1, Republicans were fighting a losing battle. After Republicans’ 2017 efforts to scale back Medicaid, Republicans got hammered in the 2018 midterms, forfeiting the House.
For Republicans, embracing Medicaid would be as smart today as it was for conservatives in the 1950s. With Medicare-for-all becoming a real possibility, conservatives should see a lot to like in a narrower state-run program focused on the disadvantaged and people in jobs that almost never have good benefits.
Medicaid is also the most cost-effective part of American health insurance. And it helps not just Republican voters, but also red states (which, because they’re typically poorer, receive higher federal contributions). In short, it’s the ideal program to signal the working-class Republicanism that Trump championed on the campaign trail but abandoned in office.
And yet, not one of the Republicans whom commentators have anointed as the coming of a Grand New Party has bucked the party’s stance on Medicaid — not Sen. Marco Rubio of Florida, not Sen. Tom Cotton of Arkansas, and certainly not Sen. Josh Hawley of Missouri. Hawley, often portrayed as the party’s populist future, has his name on the lawsuit that aims to kill the ACA. And Cotton and Rubio had an opportunity to stand up for working-class Republicans in 2017, and they backed hugely unpopular health bills that would have hit older Americans and rural areas hardest. So much for the party’s working-class reboot.
If Republicans lose big in 2020, however, their continuing adherence to these revanchist stances will prove increasingly untenable. The party has remained in power only by boosting its support among White voters without college degrees. Yet it’s these voters who are most skeptical of the health and economic policy stances that the party has used their increasingly precarious power to pursue.
In the context of relatively free and fair elections, the only question is what will give first. The commitment of elite Republicans to priorities their rank-and-file reject? Or the commitment of rank-and-file Republicans to politicians who continue to ignore their needs?