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HOUSE REPUBLICANS JUST TOUCHED THE THIRD RAIL  
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Timothy Noah
May 22, 2025
The New Republic
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_ Early this morning, House Republicans, rushed to cut not quite $1
trillion from Medicaid over the next 10 years. Today, Medicaid
commands not merely a significant voting bloc, but a significant
Republican voting bloc. _

President Donald Trump, left, and House Speaker Mike Johnson speak
with reporters after a House Republican Conference meeting at the U.S.
Capitol on May 20., Photo: Francis Chung/POLITICO // Newsweek

 

Among the more striking changes in American politics over the past
half-century is the evolution of Medicaid into a “third rail.”
House Republicans, as they rushed early Thursday morning to cut not
quite $1 trillion
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Medicaid over the next 10 years, were at best only dimly aware of
this. They’re in for a terrible shock.

Medicaid’s progress, from a stepchild program in 1965 that provided
limited health care for the indigent, into today’s much more
ambitious and capacious program serving significantly more
lower-income Americans, happened gradually. Medicaid once served a
small and politically powerless constituency that conservatives could
threaten to defund without much fear of reprisal. But today, Medicaid
commands not merely a significant voting bloc, but a
significant _Republican_ voting bloc. Not many House Republicans
wished to hear about that when they passed the budget reconciliation
bill, 215–214.

Until now, the “third rail” cliché (the metaphor being an
electrified steel subway rail that kills any who touch it) was
reserved exclusively for Social Security and Medicare. These two very
expensive programs serve people age 65 and over, a cohort that’s
long been the most powerful constituency in American politics, thanks
to elevated voter turnout (and is more numerous now as the baby boom
ages). Exempting these two programs from budget cuts is not always
good policy (Social Security benefits should be taxed more
aggressively
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high incomes), but since 1982, when Tip O’Neill aide Kirk
O’Donnell first coined the third-rail metaphor
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it’s been smart politics.

Social Security and Medicare encompass 36 percent
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federal spending. Add in interest on the national debt that absolutely
must be paid, and 47 percent
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federal spending is uncuttable. If the discussion is among Republicans
(and it usually is), then defense spending, being sacrosanct, must
also be exempted, taking 60 percent
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federal spending off the table.

You can see why Republicans are reluctant to grant Medicaid third-rail
status. It constitutes 10 percent of all federal spending; protect
Medicaid, and now you’re excluding from spending cuts 70 percent of
the total (actually a little more, because Republicans won’t likely
cut military pensions or veterans’ benefits either). Even with just
60 percent of spending off-limits, Republicans aren’t going to find
anywhere near enough in cuts to pay for $4.6 trillion in tax cuts over
the next 10 years. This week’s Freedom Caucus rebellion was about
adding a teensy bit less to the current $1.9 trillion deficit by
whacking Medicaid a little more. To characterize these rebels as
fiscal conservatives is, as I’ve noted
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preposterous.

The main vehicle for the House GOP’s Medicaid cuts is to require
Medicaid recipients to get a job. That’s pretty ironic, because the
program, as it was first implemented in 1966, _required_ Medicaid
recipients to be unemployed. Enrollment was almost entirely limited to
people receiving Aid to Families With Dependent Children, the pre-1986
cash welfare program for jobless mothers. The federal program’s
cost-sharing with the states further limited enrollment because many
states didn’t want to pay up. As late as the mid-1970s, Medicaid
still excluded about 40 percent of the nation’s poor, and enrollees
struggled to find a doctor willing to accept Medicaid patients. That
was fine by conservatives, who, according to Laura Katz Olson, a
political scientist at Lehigh University, writing in her 2010
book _The Politics of Medicaid_
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“were assuming that the program’s scope would be kept in check by
its clients’ lowly status.”

That calculus was wrong from the beginning because, unlike cash
welfare, Medicaid distributed funds directly to nursing homes,
hospitals, and physicians, all constituencies with political clout.
From the start, Medicaid also provided nursing home care to
middle-class elderly people who spent down their savings to qualify
for subsidies. States warmed to the program as they figured out clever
accounting tricks to shift more program costs to the federal
government.

Liberal members of Congress—most notably Representative Henry
Waxman, a California Democrat—quietly extended Medicaid eligibility
year after year. Waxman was aided, the Rutgers political scientist
Frank J. Thompson writes in his 2012 book _Medicaid Politics_
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by “keen negotiating skills and an understanding of how to take
advantage of budgetary rules,” which through the 1980s did not
oblige Waxman to show how much these expansions would cost. Colleen
Grogan, a University of Chicago political scientist, calls
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strategy “Grow and Hide.”

Much of the growth, however, was right out in the open. In 1997,
a Children’s Health Insurance Program
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prize after Hillarycare went down in flames—was appended to
Medicaid. Passage of the Affordable Care Act in 2010 included a
provision further expanding Medicaid eligibility, with the federal
government picking up 90 percent of the cost. Despite initial partisan
resistance by red states, today only 10 states
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to refuse the money. The price these 10 states pay for their
principled resistance is more deaths among lower-income people.
A recent paper
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economists Angela Wyse of Dartmouth and Bruce D. Meyer of the
University of Chicago (and reported by NPR
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found that those states that chose to expand Medicaid saved 27,400
lives.

A program that had only four million enrollees in 1966, and 22 million
in 1980, today has 71.3 million
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million
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you include CHIP. That’s more than Medicare, which has 68.5 million
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Let me say that again. _More people are on Medicaid than on
Medicare__._ And yes, most of these Medicaid enrollees—64 percent
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jobs. (The rest mostly attend school, take care of a family member, or
are disabled.)

In a March poll by the Kaiser Family Foundation, a 53 percent
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reported that either they or a family member had received Medicaid
coverage; when close friends were added in, that rose to 65 percent
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reported a favorable opinion of Medicaid, including 64 percent
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Republicans. Among Republicans, only 33 percent
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a federal decrease in Medicaid spending, against 67 percent
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wanted the spending level to rise or stay the same. “Medicaid, you
gotta be careful,” Steve Bannon warned in February
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“Because a lot of MAGAs are on Medicaid, I’m telling you.”

Nobody listened. Now Republicans are slashing away at at a program on
which their political base has come to rely. If the bill clears the
Senate in anything like its present form, these cuts will be extremely
bad for America. But they will also be bad for those Republicans who
signed their name to them.

_[TIMOTHY NOAH is a New Republic staff writer and author of The
Great Divergence: America’s Growing Inequality Crisis and What We
Can Do About It
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* GOP Budget
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* Trump Budget
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* Medicaid
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* Medicaid Cuts
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* Medicare
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* MAGA
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* Trump 2.0
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* Donald Trump
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* SNAP
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* Aid to Families With Dependent Children
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* Budget Reconciliation
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* Third Rail
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