In Washington’s debate over enacting steep funding cuts to Medicaid, words are a central battleground.
Many Republican lawmakers and conservative policy officials who want to scale back the joint state-federal health program are using charged language to describe it. Language experts and advocates for Medicaid enrollees say their word choice is misleading and aims to sway public opinion against the popular, 60-year-old government program in a bid to persuade Congress to cut funding.
Republicans such as Sen. Bill Cassidy of Louisiana, chair of the Senate Health, Education, Labor and Pensions Committee, are deploying provocative terms such as “money laundering,” rebranding a decades-old — and legal — practice known as provider taxes, which most states use to gain additional federal Medicaid funds.
They say it’s “discrimination” that the federal government matches state funding at a higher rate for adults covered by the Affordable Care Act’s Medicaid expansion than it does for other enrollees, including children, pregnant women, and disabled people.
And many Republicans, including House Speaker Mike Johnson and the director of the Office of Management and Budget, Russell Vought, have described adults who gained Medicaid coverage through the ACA expansion as “able-bodied” as they push for federal work requirements.
The term implies they have less need for government assistance than other Medicaid recipients — even though some have health conditions or caregiving responsibilities that make holding full-time jobs difficult.
“Able-bodied adults without dependents are better off with jobs than with hand-outs, and so are their communities and American taxpayers,” Sen. John Kennedy (R-La.) said in a press release in February.
To be sure, political spin is a practice older than Washington, and Democrats are no spectators in the war of words. But what’s striking about the latest GOP effort is that it is focused on cutting a health program for the nation’s poorest residents to pay, in part, for tax cuts for wealthier Americans.
A KFF poll conducted last month and released Friday found that support for proposed changes to Medicaid can wax or wane depending on what individuals are told about the program.
For example, the poll found about 6 in 10 adults support work requirements, with the same portion of respondents believing incorrectly that most working-age adults on Medicaid are unemployed. In fact, about two-thirds work.
KFF’s poll also showed that support for work requirements drops to about 3 in 10 adults when those who initially supported them hear that most Medicaid enrollees are already working and that, if the requirements were implemented, many would risk losing coverage because of the burden of proving eligibility.
When respondents initially opposed to work requirements were told they could allow Medicaid to be reserved for groups like the elderly, people with disabilities, and low-income children, support for them increased to 77%.
Steven Mintz, a history professor at the University of Texas, said the Medicaid debate likely will be won not on the facts, but instead on which party can describe it in terms that gain the most public support. “Words are wielded as weapons,” he said.
Republicans’ word choices are designed to appeal to people’s prejudices about Medicaid, he said, adding that “loaded” terms help divert attention from a detailed policy discussion.
“Words help reinforce a position that people already lean toward,” he said.
Sara Rosenbaum, professor emerita of health law and policy at George Washington University, said conservatives who have long tried to shrink Medicaid have an obvious motivation.
“These people spend their lives trying to ruin the program by searching for the newest slogans, the newest quips, and the newest nonsensical monikers that they think somehow will persuade Congress to completely upend the program and take benefits away from tens of millions of people,” she said.
Medicaid and the closely related Children’s Health Insurance Program cover nearly 80 million low-income and disabled people — roughly 1 in 5 Americans. Enrollment and spending soared in the past decade due largely to the covid pandemic and the decision by more states to expand Medicaid under the ACA. Polling shows the program is nearly as popular as Medicare, the health program primarily for those 65 or older — with about 3 in 4 Americans holding a favorable opinion of Medicaid.
The House of Representatives’ budget resolution, a blueprint that narrowly passed Feb. 25 with no Democratic support, calls for cuts of at least $880 billion over a decade largely from federal health and energy programs. A separate Senate resolution with no such cuts — so far — is also in play. Any proposal would need to pass both chambers.
Democrats fear most of those cuts will come from Medicaid. Trump has vowed not to touch Medicare, leaving few if any alternatives. He has said he would “cherish” Medicaid and go after only waste, fraud, and abuse in the program without offering details on how those would be interpreted — and he endorsed the House’s blueprint calling for cuts.
States and the federal government share in the financing of Medicaid, with the federal government paying from 50% to 77% of the cost of providing services to most beneficiaries. The rate is 90% for beneficiaries receiving coverage through their state’s Medicaid expansion program.
The federal matching rate varies based on a state’s per capita income relative to the national average; states with lower per capita incomes have higher matching rates. The remaining share of program funding comes from state and local sources.
The words “discrimination” and “money laundering” have been used in reports from the Paragon Health Institute, a conservative think tank led by a former Trump adviser, Brian Blase. Two former Paragon executives now advise Trump, and a former Paragon analyst advises Johnson.
Blase said there’s no ulterior motive in the group’s word choices. “This is us trying to describe the issue in a way that makes the most sense to members of Congress and policymakers,” he said.
Paragon analysts have argued for ending the federal government’s “discrimination” in matching state dollars for those covered under the ACA’s Medicaid expansion at a higher rate than for other enrollees. They also propose giving states a set amount of federal money per year for the program, rather than the open-ended federal funds that always have been a hallmark of Medicaid.
One way states raise funds for their share of Medicaid spending is through provider taxes that hospitals or nursing homes pay. States often reimburse the providers through the extra federal money.
Blase acknowledges that provider taxes used by states to draw down more federal money — which Paragon has referred to as “money laundering” — are legal. He said calling the practice a “tax” is misleading because the providers financially benefit from it.
“Money laundering is the best term we can think of for the schemes providers and states come up with to get federal reimbursement for artificial expenditures that benefits states and providers,” he said.
Joan Alker, executive director of the Center for Children and Families at Georgetown University, defended provider taxes as a legal way states raise money to cover low-income people. She noted most states with provider taxes are controlled at least partly by Republicans.
Alker rejected the notion that enhanced funding to expand enrollment is “discrimination.” The ACA included the higher rates for covering more low-income enrollees because that was the only way states could afford it, she said.
Without providing a specific example, Blase said advocates have said cuts would “leave people dying in the streets.”
During a brief funding freeze to Medicaid providers in January, Sen. Ron Wyden of Oregon, the top Democrat on the Senate Finance Committee, said, “This is a blatant attempt to rip away health insurance from millions of Americans overnight and will get people killed.”
Excerpts or more from this article, originally published on KFF Health News appear in this post. Republished, with permission, under a Creative Commons License.
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