Nationally, 77% percent of voters hold a favorable opinion of Medicaid, including 81% of independents and 63% of Republicans. (Stock photo by L Pettet/Getty Images)
Let’s start at a place where we can all agree: In a nation of 340 million people, systems designed to serve the needs of such a large population will be imperfect. Public education is imperfect. The justice system is imperfect. Medicaid is imperfect. Social Security is imperfect. Taxation is imperfect. Road maintenance is imperfect.
Pick a system, at any level of government from local to federal, and you will find proof of defect.
It is when we try to move forward together from that point of unity that the nation’s major fault lines emerge. We can’t agree on what exactly is broken, who is to blame, or how (or whether) we should go about the repairs.
Last week, I wrote that the fundamental tension in New Hampshire and the United States — the primary fault line — stems from a dispute over how public money should move. The defining position of the right is that the potential for prosperity among the masses is directly tied to how much the government invests in its wealthiest citizens, through tax breaks for example, and the left traditionally argues that direct investment in the masses, including through programs like Medicaid and Social Security, will lead to broader prosperity and therefore a stronger nation.
Fundamentally, Americans agree that our public systems are imperfect. And, fundamentally, we are divided over the scope and value of many of those systems.
The Republican Party has long framed its efforts to dismantle systems as a desire for small government. From a political marketing perspective, that’s a wise choice. “Small-government conservative” suggests efficiency, and who doesn’t love efficiency. But their efforts are rarely surgical — despite rosy monikers like the federal “Department of Government Efficiency” or New Hampshire’s “Commission on Government Efficiency” — and so the combination of administrative layoffs and reduced funding end up making the systems even more inefficient, more fully broken. And often that’s the point — to break public systems to the degree that they are no longer worth fixing — because ultimately Republicans want that money to go to private industry.
The harm from that approach is direct and it is immediate. Medicaid, for example, serves more than 180,000 people in New Hampshire, according to KFF, a nonpartisan organization that provides health policy research. The program covers 64% of the state’s nursing home residents, 30% of its children, and 31% of working-age adults with disabilities. Nationally, 77% percent of voters hold a favorable opinion of Medicaid, including 81% of independents and 63% of Republicans.
But during the last legislative session, Gov. Kelly Ayotte signed a budget that increased premiums and established work requirements, amid other punitive changes to the program. After the governor signed House Bills 1 and 2, a coalition of 80 health care providers and advocates said, “These policies will shift more costs to families and low-wage individuals, imposing significant financial burdens and limiting access to care for some of New Hampshire’s most vulnerable residents.”
And, the group continued, “Beyond the direct impacts on individuals and families, safety net providers will face increased uncompensated care costs unless the state takes proactive steps to protect coverage.”
You see, in order for Republican lawmakers to continue investing in the wealthiest Americans, the money has to come from somewhere. That “somewhere” is a magical place called “smaller government,” which is really a wasteland of reduced services for poor people, people with disabilities, and residents who require nursing home care.
In New Hampshire, that translates into heavier burdens placed on low-income residents in order to pay for the elimination of the interest and dividends tax, the expansion of school vouchers to benefit high-income families, and a years-long series of aggressive business tax cuts. Among the “efficiencies” gained from this “small government” approach is a decline in care and support for already underserved populations, more economic pressure placed on property-poor towns by way of expanded school vouchers, and the forfeit of a tax paid largely by upper-income residents. And, to be clear, when I say this was a tax paid by rich people, I mean more than half of the payers of the interest and dividends tax (which brought in more than $180 million in 2024) made in excess of $200,000 in income from interest and dividends alone. How much base wealth does it even take to earn more than $200K just in interest and dividends?
Nationally, the Republicans have been even more aggressive in undermining a program that has the support of more than three-quarters of the country. That “big, beautiful bill” the GOP is so proud of cuts $1 trillion from Medicaid over the next decade to pay for a $1 trillion tax cut for the richest 1%. The primary “efficiency” gained is that another 15 million low-income Americans will join the 25 million people who were uninsured even before Donald Trump’s mega-bill was signed into law.
Will any of the $1 trillion taken from low-income people and given to the highest income people ever make its way back to the people at the bottom? That is the very foundation of the Republican platform, but the overwhelming evidence — via rapidly expanding economic inequality — says that’s not what happens at all. Money that could spare a family from having to choose between groceries and health care is instead going to those among us who are fortunate enough, for example, to collect more than $200,000 a year just in interest payments.
In what way is any of that a good deal for the masses, now or even in some imagined future?
But let’s return, just for a second, back to that original point of unity in America: Our systems, including Medicaid, are imperfect. Before we take another step and become mired once again in political confrontation, how about one more place at the beginning where we can stand together: Less suffering is preferable to more suffering.
More than anything, that is my political position. Odds are it’s yours, too. Where, I wonder, can we go from there?