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.”