ANALYSIS: HEALTH CARE

Obama Rebrands Medicaid as a Crucial Middle-Class Entitlement

The president’s campaign message to middle-class voters: This insurer of last resort for the poor helps you, too.

Former president Bill Clinton gives the closing remarks of the second to last night of the Democratic National Convention. 
National Journal
Margot Sanger Katz
Nov. 1, 2012, 5:48 a.m.

If you look at the num­bers, Medi­caid is mostly for poor people. The fed­er­al-state health care pro­gram””part of the so­cial-safety net built by Pres­id­ent John­son in the 1960s””in­sures more than 63 mil­lion Amer­ic­ans, most of whom have in­comes be­low the poverty line.

But if you’ve been listen­ing to Pres­id­ent Obama, you can be for­giv­en for think­ing that Medi­caid primar­ily serves the dis­abled chil­dren and eld­erly par­ents of middle-class Amer­ic­ans. In cam­paign ad­vert­ise­ments and pres­id­en­tial de­bates, Obama has ef­fect­ively rebranded Medi­caid as a middle-class pro­gram, rather than an in­surer of last re­sort for the poor. After all, middle-class voters are more likely to vote for the man who will pro­tect Medi­caid if they think it is for them.

In a ra­dio ad run­ning in sev­en battle­ground states, a soc­cer mom de­scribes how she is the “air-traffic con­trol­ler” for her fam­ily, shut­tling between work, school, and her chil­dren’s activ­it­ies. Then she men­tions that her fath­er’s in a nurs­ing home and her dis­may that Rom­ney’s budget plan would lim­it fed­er­al fund­ing for Medi­caid, which she calls “something middle-class fam­il­ies rely on to pay for nurs­ing-home care, Medi­caid that sup­ports chil­dren strug­gling with dis­ab­il­it­ies like aut­ism or Down syn­drome.” Two tele­vi­sion ads fo­cus on the pro­gram’s role in “help­ing middle-class fam­il­ies” pay for their re­l­at­ives’ nurs­ing-home care. Miss­ing from all of these ads: the word “poor.”

Pres­id­ent Clin­ton may have ushered in this ap­proach. In his Septem­ber con­ven­tion speech, he noted how badly cer­tain middle-class fam­il­ies need the pro­gram and the chal­lenges they would face if Medi­caid were cut. “If that hap­pens, I don’t know what those fam­il­ies are go­ing to do,” he said. Obama echoed the sen­ti­ment dur­ing the Den­ver de­bate, when he de­scribed Medi­caid as the “primary pro­gram” for “seni­ors who are in nurs­ing homes, for kids who are with dis­ab­il­it­ies.”

It’s true that Medi­caid helps middle-class nurs­ing-home pa­tients (who qual­i­fy after they spend down their sav­ings) and dis­abled chil­dren, but these groups rep­res­ent a minor­ity of its be­ne­fi­ciar­ies. About 75 per­cent of Medi­caid re­cip­i­ents””some 47 mil­lion people in 2009, the latest year for which data are avail­able””qual­i­fy be­cause of their low in­comes. Polls from the Kais­er Fam­ily Found­a­tion have found that more than half of all Amer­ic­ans had either re­lied on Medi­caid them­selves or had a fam­ily mem­ber or close friend who did. More than one-third of Amer­ic­an chil­dren are cur­rently en­rolled.

In a cer­tain way, Medi­caid is a middle-class pro­gram. In terms of dol­lars spent, the eld­erly and dis­abled rep­res­ent 66 per­cent of the pro­gram’s costs, about $228 bil­lion in 2009 (since which time en­roll­ment has only grown). Those groups re­quire much more ex­pens­ive care, and they are much less healthy than those who are merely poor. They are also less likely to find sim­il­ar cov­er­age on the private mar­ket, even if they could af­ford it. Ac­cord­ing to the Kais­er poll, only 15 per­cent of those who had con­tact with Medi­caid were linked to nurs­ing-home care.

Medi­caid al­most nev­er plays a role in pres­id­en­tial polit­ics, so this de­bate is un­usu­al. Medi­care, the be­loved health in­sur­ance pro­gram for the eld­erly, is a per­en­ni­al theme (thanks to the seni­or vote), but when the Obama cam­paign re­leased its first Medi­caid-themed TV ad last month, a long­time ad­voc­ate tweeted, “Thought I’d see pigs fly be­fore I saw a pres­id­en­tial cam­paign ad on Medi­caid.” Sev­er­al ana­lysts said they couldn’t re­mem­ber a single Medi­caid ad in a past pres­id­en­tial cycle. “It was nev­er in a na­tion­al race that I know,” says Robert Blendon, a pro­fess­or at the Har­vard School of Pub­lic Health.

Ex­perts say that the new fo­cus on middle-class Medi­caid re­cip­i­ents has sev­er­al ob­ject­ives. It’s de­signed to stoke the anxi­et­ies of middle-aged Amer­ic­ans, who shoulder the bur­den of caring for their eld­erly par­ents but are less con­cerned about pro­posed changes to the Medi­care pro­gram that they won’t join for years. It il­lus­trates which be­ne­fi­ciar­ies could be most hurt by cuts, by high­light­ing those whose spend­ing rep­res­ents the ma­jor­ity of pro­gram dol­lars. It also high­lights a big policy dif­fer­ence between the two can­did­ates while avoid­ing the stigma of­ten at­tached to means-tested gov­ern­ment pro­grams. Par­ents of dis­abled chil­dren and chil­dren of aging par­ents are less likely to dis­dain gov­ern­ment help when their re­l­at­ives, rather than dis­tant poor people, are re­cip­i­ents. “Those are groups that garner the most em­path­et­ic re­ac­tion from the Amer­ic­an pub­lic,” says Mol­ly­ann Brod­ie, Kais­er’s poll­ster. “It taps in­to the vul­ner­ab­il­it­ies people feel.”

If the tac­tic works, the middle-class meme could find its way in­to fu­ture Demo­crat­ic cam­paigns””not to men­tion the com­ing de­fi­cit-re­duc­tion talks. The Af­ford­able Care Act ex­tends cov­er­age to about half of the new re­cip­i­ents through an ex­pan­sion of Medi­caid, so any strategy that builds pub­lic sup­port for Medi­caid will help pro­tect Obama’s health care law. “The com­mu­nic­a­tions maes­tros out there are go­ing to con­tin­ue push­ing that,” says Shawn Grem­minger, the as­sist­ant vice pres­id­ent for le­gis­lat­ive af­fairs at the Na­tion­al As­so­ci­ation of Pub­lic Hos­pit­als and Health Sys­tems and the au­thor of the “pigs fly” tweet. But Grem­minger frets that gen­er­ic sup­port for Medi­caid could erode its repu­ta­tion as a ba­sic safety-net pro­gram. “I worry that it could di­vide the Medi­caid world.” By fo­cus­ing on the most sym­path­et­ic quarter of be­ne­fi­ciar­ies, it could un­der­mine sup­port for the rest.

This art­icle ap­peared in print as “Rebrand­ing Medi­caid.”

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