Medicaid is in the Constitution

That’s a bold statement, and it’s inaccurate in the sense that if you read our Constitution you won’t find the word “Medicaid” in it. Medicaid is a federal program created in 1965 as part of a series of amendments to the Social Security Act of 1935. Here’s a quick, neutral definition of Medicaid from Wikipedia:

“Under the program, the federal government provides matching funds to states to enable them to provide medical assistance to residents who meet certain eligibility requirements. The objective is to help states provide medical assistance to residents whose incomes and resources are insufficient to meet the costs of necessary medical services. Medicaid serves as the nation’s primary source of health insurance coverage for low-income populations.

States are not required to participate. Those that do must comply with federal Medicaid laws under which each participating state administers its own Medicaid program, establishes eligibility standards, determines the scope and types of services it will cover, and sets the rate of payment. Benefits vary from state to state, and because someone qualifies for Medicaid in one state, it does not mean they will qualify in another.”

Millions of Americans rely on Medicaid (and the related Medicare) for medical care. All of them are poor–officially living below the poverty threshold as defined by the federal government. In 2017, for instance, the poverty threshold for a household of four people is $32,300. Most Americans who receive Medicaid are elderly. Many are disabled, many are veterans, many are children.

Medicaid, then, is a federal safety net like Social Security that is meant to maintain a basic standard of living for the poorest, oldest, and youngest Americans.

When the Affordable Healthcare Act (Obamacare) was passed, it required Americans to have health insurance. If someone lives below the poverty line, Medicaid pays for that insurance. To make this happen, the federal government offered all states more money for Medicaid.

18 states, all but two with Republican governors or legislatures, refused to take this extra funding for Medicaid. Some representatives of these states claimed they wanted to draft their own Medicaid “reform” legislation; others, like Maine’s governor LePage, claimed it was just an attempt by the Democratic party to create a “massive increase in welfare expansion.”

That word—“welfare”—has become a charged word in the U.S. Like “liberal”, which means “generous”, welfare is a positive word that has been given a negative meaning by its opponents. “Welfare” means “the good fortune, health, happiness, prosperity, etc., of a person [or] group”. You can see its English root pretty clearly: “fare” means “to experience good or bad fortune”; if you fare well, that’s good. Then you have welfare. We maintain this understanding when we tell people “farewell” when they leave on a trip. We want to wish them a good experience, safety, and happiness.

But conservatives who oppose any government spending on social safety nets turned our federal welfare system into a whipping boy in the 1980s, under President Reagan. The infamous “welfare queen” Reagan wowed audiences with—a woman who supposedly bilked the federal system to the tune of $150,000 a year—was used by conservatives to damn the program. They said people on welfare were lazy (code word for “black”), and that all hard-working, middle-class Americans (code words for “white”) were paying to support these people who laid around eating candy and watching TV all day. Why should they go get jobs? They were living the good life on our dime. If we got rid of welfare (shorthand for all federal safety net programs, from food stamps to subsidized school lunches to Head Start), the conservatives said, all of those people would have to go out and get jobs, and we’d all be better off.

To help make this happen, Reagan’s administrations cut funding to the programs, and subsequent Republican lawmakers and presidents continued this trend. They also began cutting taxes sharply under George W. Bush. With less money coming into the federal government, less money could go to states to support programs like Medicaid and SNAP (food stamps). States began to cut services, often by making the poverty threshold lower and lower.

These cuts in funding exacerbated the problems of the poor who depended on them. They also coincided with stagnating incomes, a stubbornly low minimum wage, and a forced shift of workers to part-time employment by companies that did not want to pay full-time wages or offer full-time benefits to make the traditionally poor even poorer, and to move working people who used to make enough money to live on into the poverty range, where they need federal assistance.

Despite the fact that “the poor” includes white people, people who are working, children, veterans, and elderly people who worked all their lives, conservatives today continue to slam “welfare” as a trap set by devious immigrants, blacks, and criminals to trick honorable working white people into giving away their money.

Welfare. Despite all of this recent effort to make it a bad word and an even worse idea, welfare actually is in the Constitution. Let’s revisit that famous Preamble (and sing it in our heads to the Schoolhouse Rock melody):

We, the People of the United States, in Order to form a more perfect Union, establish Justice, ensure domestic Tranquility, provide for the common defense, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity do ordain and establish this Constitution for the United States of America.

“Promote the general Welfare”: that’s written into the fabric of our national identity, the purpose of our nation. One of our fundamental reasons for being is to ensure that every American has the full opportunity to experience the Blessings of Liberty. This is an idea that was first expressed by English settlers in 1630, when Puritan John Winthrop said, in what we call the “City on a Hill” speech,

…we must be knit together in this work as one man, we must entertain each other in brotherly Affection, we must be willing to abridge our selves of our superfluities, for the supply of others necessities, we must uphold a familiar Commerce together in all meekness, gentleness, patience and liberality, we must delight in each other, make others Conditions our own, rejoice together, mourn together, labour, and suffer together, always having before our eyes our Commission and Community in the work, our Community as members of the same body, so shall we keep the unity of the spirit in the bond of peace, the Lord will be our God and delight to dwell among us, as his own people and will command a blessing upon us in all our ways…

As we note in our original post, this is a beautiful passage, reminiscent of the Sermon on the Mount in its focus on mercy, kindness, sharing, and other selfless qualities. The Puritans will not succeed by harrying out the sinner or otherwise smiting evil, but by loving each other, caring for each other, and “abridging our selves of our superfluities, for the supply of others necessities” (that is, there will be equality of wealth, with no one living in luxury while others starve). They will delight in each other,  making others’ conditions their own, and they will do all this to create a natural community of faith.

That’s what America was still dedicated to in 1787 when the Constitution was written and ratified by popular vote. We dedicated ourselves to giving some of our own wealth to provide for others. We dedicated ourselves to “liberality”, meaning generosity. We dedicated ourselves to Community, to seeing ourselves as members of the same body, living in a unity of spirit.

In short, we committed ourselves to the “general Welfare”, as the Constitution says. Americans must remember this in an age where we are urged to believe that “rugged individualism” is our true creed, and urged to say “no one helped me so why should I help anyone else?” and “I take care of my own.” Medicaid, food stamps, subsidized school breakfasts and lunches, Social Security, and everything else slighted now as “welfare” are really avenues toward establishing and maintaining the general Welfare our Founders envisioned. No nation is rich if it refuses to create equality of opportunity for all its citizens. No nation ends poverty claiming it is a trick played on the nation by the poor. No nation but the United States made generosity a cornerstone of its political outlook and purpose. Let’s remember that, and live up to our own creed.


8 thoughts on “Medicaid is in the Constitution

  1. I disagree with a ton of your points. Statistically, you’ll find African Americans and Hispanics, once adjusted for their population percentage, do use more welfare than whites. Source: (

    Having personally witnessed hundreds of cases of welfare fraud, I can assure you that your statement “All of them are poor–officially living below the poverty threshold as defined by the federal government,” is false. The most egregious case I knew of was a dentist / city council woman, who intentionally fostered kids with disabilities. This gave her increased welfare payout for those kids, access to their controlled amphetamines, and preferential government contracts to her family. She made six figures as a dentist. Lesser cases involved selling narcotics paid for by medicaid (very common.)

    Also the constitution states “promote the general Welfare.” Which our current entitlement system does not do. It promotes welfare to specific people, at the expense of others (some of whom are just as poor.) When I was poor and hungry, I still paid medicaid taxes, even though I hadn’t eaten in days sometimes. I remember being jealous of fat people. Or am I not included in the general population?

    This and a more thorough response will be on my blog to prevent censorship. Cheers! I always link to the author’s blog first when I do this to make sure they get credit.


    1. Before you post further you should revisit your understanding of “promote the general welfare”. It means everyone chips in according to their ability (in this case, income/tax bracket) to help those in need so that the whole nation benefits. Poor Americans are often taxed unfairly as tax cuts accrue only to the wealthy, which may account for your personal experience. A system that is meant to do good but perverted into failing is not an indictment of the system and its goals, but of those who pervert it.


      1. Perhaps without meaning to, you just paraphrased one of the principles of the Communist Manifesto – to each according to his need, from each according to his ability. Sorry, but that is not the meaning of the General Welfare Clause. Furthermore, the Preamble to the Constitution is a statement of purpose, not a basic law. The Articles and Amendments are basic law. Your understanding of “promote the general welfare” is completely ahistorical, i.e. completely at odds with the original understanding of the term. See my previous post. The Supreme Court changed its meaning in its decision in Helvering v. Davis in 1937, one of more than a dozen decisions that improperly rewrote the Constitution. FDR and his administration decided not to try to amend the Constitution as provided for in Article V to establish social security, and most people in government at the time expected that the Court would overturn the section of the Social Security Act that distributed old age benefits. The taxation portion of the Social Security Act is authorized by the Article I, Section 8, Clause 1, statement giving the Congress the power to lay taxes, and by 16th Amendment’s authorization for Congress to levy taxes on income.

        In a democracy, where all citizens are equal before the law, I believe that the appropriate personal income tax plan is a flat tax – then all taxpayers pay the same percentage.


      2. The principle expressed in the Communist Manifesto is pretty general–enough so that it cannot be reserved only to communism. We maintain that the 18th-century understanding of the word “welfare” was indeed “the good fortune, health, happiness, prosperity, etc., of a person, group, or organization”, and that this word and concept are included in the Preamble as one of the framing principles of the laws that would follow in the Constitution. “General” likely meant “of all the states”, as it was imperative that the uniting of different states gave equal benefit to all–a desire that made figuring out representation to Congress for states of different populations very difficult.

        Even with a flat tax, those who earn more pay more, to help provide services for those with less, and that is the basic idea of federal welfare.


      3. I am glad that we agree on a flat tax. Now to the main topic.

        The question at hand is whether Medicaid is constitutional. The short answer is that the Supreme Court has never heard a case in which Medicaid’s constitutionality was questioned. But Medicaid is considered to be constitutional, because (a) the Court did not declare it to be unconstitutional in its 2012 decision in NFIB v. Sibelius, when it considered the expansion of Medicaid as part of the Affordable Care Act, and (b) when Medicaid was established in 1965, it was enacted by amending the Social Security Act of 1935; this Act was approved by the Supreme Court in several 1937 cases. Medicaid, by default, is therefore constitutional.

        However, by far the more interesting question is whether Medicaid (and Social Security) can survive a careful reading of the Constitution, and the answer is that they cannot. Even in 1937, when the Court was hearing the Social Security cases, most informed observers expected the Court to overturn at least some portions of the Act. Medicaid and, by implication, Social Security, are constitutional only because the Court in 1937 decided to approve the Social Security Act, and thus gave Congress a new power that was it never intended to have. The remainder of this essay will explain the logic of this view.

        If we view the Constitution as a sturdy wall surrounding and limiting the powers of the federal government, a major breach in that wall has been created by the misuse of the term “general welfare.” These words appear in both the Preamble and Article I, Section 8, Clause 1. The wording is understood by some to give Congress an open-ended authority to fund any and all projects which, in the opinion of Congress, advance the public good. The purpose of this essay is to demonstrate that this understanding is incorrect.

        Let us begin by considering the Preamble’s declaration that one of the purposes of the Constitution is to “promote the general welfare.” Two important facts are pertinent. First, the Preamble, like any other preamble, is not law. It is an eloquent statement of purpose, but it has no standing as enforceable or actionable law. Thus, to use the general welfare wording in the Preamble to assert that the federal government has the general power “to promote the general welfare” is simply incorrect. Second, while the Constitution’s primary purposes were to define the structure, functions, and limits of the three Branches of the federal government, the Constitution applies equally to State governments, although this fact is often overlooked.

        For example, each of the four clauses of Article IV applies to the States, as do the three clauses of Article VI. Clause 1 of Article VI tells the States indirectly that the United States will be responsible for all debts and agreements “entered into, before the adoption of this Constitution,” even though Clause 1 does not include the word “States.” Nonetheless, the history of Clause 1 makes it very clear that states’ revolutionary debts were to be assumed by the federal government. Other examples: Article I, Section 2, requires the “executive authority” in a state to appoint replacement Members of Congress when necessary; Article I, Section 3, in its original form, required state legislatures to appoint Senators; and Article I, Section 10, lists fifteen actions which are either forbidden, or permitted conditionally, to the States. Finally, the Tenth Amendment makes it clear that state sovereignty is preserved for all powers which are neither delegated to the United States nor prohibited to the States.

        Since the Constitution applies to the States, as just demonstrated, not just to the federal government, the Preamble must also be understood to encompass the States. Thus, it is entirely reasonable to conclude that the States were intended to be equal partners with the federal government in promoting the general welfare and the other purposes listed in the Preamble. Accomplishing these purposes was not intended to be solely a federal responsibility.

        In order to understand the powers granted to the federal government, especially the powers of the Congress to put these purposes into execution, requires that we examine Section 8 of Article I. Clause 1 of Section 8 includes the words “general welfare.” The discussion which will follow in Part 2 of this essay carefully examines the wording and meaning of this clause.


      4. Describing the Constitution as “a sturdy wall surrounding and limiting the powers of the federal government” is one interpretation, and far from an objective analysis of the Constitution’s purpose. The Constitution provides a foundation for law-making. It could well be described as a sturdy foundation on which the federal government can pass legislation and take action domestic and foreign.”

        And as you agree that the Preamble is a statement of purpose, then its call to provide for the general welfare is part of that foundation.


  2. Since the meaning of “the general welfare” is open-ended, with no limits other than it be general, then what was the point of the Founders in listing the powers delegated to Congress in Article I, Section 8? Think about this for a moment or two. In other words, there is thus a major disconnect between the (mis)understanding of “the general welfare” in the assertion that Medicaid, Medicare, and Social Security are constitutional, and the care with which the Founders listed the specific powers delegated by “the people” to Congress. In his later correspondence, Madison made exactly this point. Finally, the clincher is that the participants in the Federal Convention and in the state ratifying conventions had one overriding concern – a central government that would over power the states and the people and become tyrannical. A little more research would have revealed that the use of “the general welfare” was simply a shorthand reference to the enumerated powers of Article I, Section 8, and was a term that was lifted from the Articles of Confederation (as were numerous other terms that appear in the Constitution).


    1. Hello Mike; the first “bullet” in that list in 1:8 is “To lay and collect Taxes, Duties, Imposts and Excises, to pay the Debts and provide for the common defence and general Welfare of the United States; but all Duties, Imposts and Excises shall be uniform throughout the United States”. Does this not seem to apply to social safety nets from the federal government? And besides that, those social welfare programs are open-ended, being whatever Congress deems necessary. So we’re not sure we’re getting your point and would love to hear more.


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