By Lakshya Jain, Harrison Lavelle —
As Republicans crafted their One Big Beautiful Bill, Sen. Josh Hawley (R-Missouri) offered a warning: “Our voters support social insurance programs. More than that, our voters depend on those programs.”
While House Republicans ignored his pleas, opting to pass a bill with cuts to Medicaid that the Congressional Budget Office estimates would lead to 7.8 million fewer people with coverage, Hawley was onto something. There’s strong evidence that voters whom President Donald Trump brought into the Republican Party over his three presidential runs will be especially affected by the proposed funding changes to health care.
A quick glance at the counties with the biggest Republican swings in the Trump era bears this out: In county after county and state after state, Trump made disproportionate gains among lower-income voters, many of whom rely on Medicaid – a program that covers nearly 80 million Americans nationwide.
In fact, in counties where more than one-quarter of the population is on Medicaid, Trump gained 17 percentage points in terms of margin, on average, over the party’s 2012 performance, more than double his average gain in counties with low Medicaid enrollment rates. And though county results can’t identify which individual voters shifted toward the GOP, polls and post-election analyses consistently found Trump improved with lower-income voters who tend to be more affected by health-care cuts.
You can point to many reasons for Trump’s gains in lower-income regions, but the most relevant one might also be the simplest: Unlike many establishment Republicans, Trump repeatedly promised to not touch social welfare programs such as Medicare, Medicaid and Social Security.
It’s hard to overstate just how dramatically Trump’s approach differed from those of prior Republican campaigns. In 2012, for example, Mitt Romney was caught on tape saying that 47 percent of the country was reliant on government benefits and hopelessly out of reach to Republicans, while his vice-presidential nominee, Paul D. Ryan, proposed a program to reshape and partially privatize Medicare to lower costs.
Perhaps as a result, Trump’s 2016 campaign yielded major gains for Republicans among voters inclined toward expanding the social safety net. According to Democratic data scientist David Shor, Trump gained 40 percentage points in margin among voters who supported universal health care but opposed amnesty. The signs of this were visible throughout the cycle; even in the 2016 primary, Trump’s strongest supporters were self-identified Republicans who were registered as Democrats, hinting at greater support for government welfare programs among new converts.
Trump backtracked on his Medicaid promise in his first term, and his proposals to partially repeal the Affordable Care Act and cut Medicaid spending helped fuel sweeping Democratic gains in 2018. His One Big Beautiful Bill comes with similar risks, and negative reactions are already showing up in surveys – including among his supporters. According to a KFF survey last month, 69 percent of Republicans on Medicaid and 62 percent of low-income Republicans are at least “somewhat worried” about cuts to the program. And more than 4 in 10 respondents covered through Medicaid or the Affordable Care Act’s marketplaces – where benefits will also shrink next year – identified as Republican.
Trump won’t be on the ballot again, but his allies in Congress also face exposure to a backlash against health-care changes. Many House Republicans, including those in swing seats, now represent districts with high Medicaid enrollment rates, opening new political vulnerabilities. In fact, several battleground Republicans represent districts in which over 20 percent of the eligible population is on Medicaid – and many of them won only narrow victories in 2024.
In the face of all these developments, it’s also important to remember that the Republican coalition has changed massively since 2012, with a large portion of the well-educated, suburban electorate that backed Romney now voting Democratic at the federal level. If GOP cuts end up pushing lower-income voters they have picked up in the past three cycles back to the Democrats, Republicans will not have the same suburban base to fall back on. In essence, Republicans risk repelling their newest voters after having lost many of their old ones.
At the same time, the influence of culture-war issues shouldn’t be discounted. Much of Trump’s base could end up sticking with the GOP in the years to come, even while objecting to Medicaid changes, if voters continue to perceive Democrats as too socially progressive or focused on the wrong issues.
Regardless, the past 15 years of high-profile political fights around health care – and accompanying election losses for both parties – are a testament to the fact that voting blocs cannot be taken for granted in politics. Trump repeatedly persuaded many voters outside the Republican Party’s typical base to join his coalition. The durability of this new coalition remains to be seen, and the midterm reaction to his One Big Beautiful Bill will be an important test of its staying power.
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Lakshya Jain and Harrison Lavelle are partners at Split Ticket, an election data analysis firm.
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