Medicaid and the Struggle for Universal Health Care in the Trump Aftermath

Health care provision in the United States stands at a crossroads. As this paper goes to press, the Trump administration is launching an unprecedented assault on key public health insurance programs that will result in the loss of coverage for as many as 17 million people.^[1] The bulk of the coverage loss will come in the form of cuts to Medicaid — the joint federal-state program that covers one in five Americans. This is the largest cut to Medicaid in the program’s history, and is within the range of coverage losses the US would have experienced had Republicans successfully passed at least one of their proposals to repeal and replace the Patient Protection and Affordable Care Act (also known as Obamacare).^[2] Republicans’ 2025 budget reconciliation legislation, which will be enacted despite wide public disapproval, will have devastating effects on huge swaths of the American economy, including health care systems and rural hospitals.  

In the face of these challenges, proponents of expanding and universalizing health coverage will be forced to confront a new strategic reality. Now that years of incremental expansions to a fundamentally fragmented and unequal health care system have redounded to rising prices, towering medical debt, dismal health outcomes, and bouts of retrenchment, there is no alternative to advancing the cause of universal health care. The only question is where to concentrate efforts to build up the political power of the working class to advance this cause.  

This briefing paper argues that defense and expansion of Medicaid is the most promising focal point around which to coordinate working-class political mobilization towards delivering universal coverage. While the program’s fragmented structure and means-tested design poses significant challenges for organizing a broad based and mobilized coalition, Medicaid has grown into both a cornerstone of the US health care system, and hence the American economy, as well as a lifeline for the working class. The central argument advanced here is that Medicaid’s internal contradictions can be leveraged to build a working-class coalition capable of advancing universal health coverage.  

In searching for the seeds of a reform coalition, other strategies have focused on populations covered by the Affordable Care Act’s individual marketplaces, which enroll a small percentage of the US middle class who lack access to employer-sponsored insurance, as well as the Medicare population, which largely lacks the structural power.^[3] While no doubt useful, these approaches would do less to harness the latent political power of the mass working class than would a Medicaid-focused approach. In short, Medicaid’s relationship to state economies and its significance for working-class communities — as both patients and workers in the health care sector dependent upon Medicaid funding — creates important opportunities for political organizing.

Linking the struggle of beneficiaries to that of health care workers is particularly important given that workers possess sources of structural power in the economy. And while Medicaid beneficiaries are typically harder to mobilize than the beneficiaries of other programs (given the class bias in the composition of the American electorate), the program’s contradictions create mobilizing opportunities that have not yet been exploited. Medicaid occupies a different strategic position today than it did when the ACA was first passed. Following the passage of that law, millions of working-class Americans were added to the program’s rolls. If the 2025 budget reconciliation bill is implemented as designed, those millions are now poised to experience losses in coverage. More than mobilizing these individuals to push for a restoration of benefits they have lost, there is an opportunity here to go further, building power to support non-reformist reforms.

This paper begins with a brief primer on Medicaid — including on its administrative structure and financing. The second section sketches out the political economy of Medicaid, dissecting the puzzle of how the program has grown despite the political demobilization of its own beneficiaries. Drawing on this analysis, the third section outlines a strategic framework for leveraging Medicaid’s contradictions to build working-class power, connecting immediate defenses of the program to the longer-term goals of universal health coverage.