Medicaid advocates say critics are using loaded terms to gain an edge in the congressional debate

Medicaid advocates say critics are using loaded terms to gain an edge in the congressional debate

In Washington's debate over pursuing steep funding cuts to Medicaid, words are a key battleground.

Many Republican lawmakers and conservative policy officials who want to reduce the shared federal health care program are using charged language to describe it. Language leaders and advocates for Medicaid enrollees say their choice of words is misleading and want to sway public opinion against the 60-year-old government program to persuade Congress to cut funding.

Republicans like Sen. Bill Cassidy of Louisiana, chairman of the Senate Health, Education, Labor and Pensions Committee, used provocative terms like “money laundering” to rename a decades-old—and legal—provider tax practice that most states use to obtain additional Medicaid funds.

They say it is "discrimination" that the federal government matches state funding at a higher rate for adults covered by the Affordable Care Act's Medicaid expansion than for other enrollees, including children, pregnant women and disabled people.

And many Republicans, including House Speaker Mike Johnson and Office of Management and Budget Director Russell Vought, have described adults who gained Medicaid coverage through the ACA expansion as "capable" when pushing for federal work requirements.

The term implies that they require less government assistance than other Medicaid recipients—although some have health conditions or caregiving responsibilities that make full-time work difficult.

“Jobs are better off than workers, as are their communities and American taxpayers,” Sen. John Kennedy (R-La.) said in a press release in February.

Of course, political spin is a practice that predates Washington, and Democrats are no spectators to the war of words. But what's impressive about the latest GOP effort is that it focuses on cutting a health care program for the country's poorest residents, who can partially pay for tax cuts for wealthier Americans.

A KFF poll conducted and released last month found that support for proposed changes to Medicaid can ebb and flow depending on what individuals are told about the program.

For example, the survey found that about 6 in 10 adults support work requirements, with the same share of respondents incorrectly believing that most working-age adults are unemployed for Medicaid. In fact, about two-thirds work.

KFF's survey 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 already work and that if the requirements were implemented, many would risk losing coverage since eligibility has been proven.

When respondents initially opposed work requirements, allowing Medicaid to be reserved for groups such as the elderly, people with disabilities and low-income children increased to 77%.

Steven Mintz, a history professor at the University of Texas, said the Medicaid debate will likely be won not on the facts, but on which party can describe it in terms that retain public support. “Words are wielded as weapons,” he said.

Republicans' word choices are intended to address people's biases toward Medicaid, he said, adding that "loaded" terms divert attention from a detailed policy discussion.

“Words reinforce a position that people are already leaning towards,” he said.

Sara Rosenbaum, professor emerita of health law and policy at George Washington University, said conservatives who have long sought to shrink Medicaid have an obvious motivation.

“These people spend their lives trying to ruin the program by looking for the latest slogans, the latest quips and the latest nonsensical monikers that they believe will somehow convince Congress to completely improve the program and take away benefits 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 - about 1 in 5 Americans. Enrollment and spending increased over the past decade largely due to the Covid pandemic and more states' decisions to expand Medicaid after the ACA. Surveys show the program is almost as popular as Medicare.

The House budget resolution, a blueprint narrowly passed on February 25 without Democratic support, calls for cuts of at least $880 billion over a decade largely from federal health and energy programs. A separate Senate resolution without such cuts is also in play. Any proposal would have to pass both chambers.

Democrats worry that most of these cuts will come from Medicaid. Trump has vowed not to touch Medicare, leaving few if any. He has said he would "value" Medicaid and only "go after waste, fraud and abuse" in the program, without providing details about how those would be interpreted - and he endorsed the House blueprint that called for cuts.

States and the federal government share in funding 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 under their state's Medicaid expansion program.

The federal adjustment rate varies depending on a state's per capita income compared to the national average. Countries with lower per capita income have higher adjustment rates. The remaining portion of program funding comes from state and local sources.

The words “discrimination” and “money laundering” were used in reports from the Paragon Health Institute, a conservative think tank led by former Trump adviser Brian Blase. Two former Paragon executives now advise Trump, and a former Paragon analyst advises Johnson.

Blase said the group's word choices don't give them a back-border motif. “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 advocated for ending the federal government's "discrimination" in state dollars for those covered under the ACA's Medicaid expansion at a higher rate than for other participants. They also propose giving states a fixed amount of federal money per year for the program, rather than the open federal funding that has always been a hallmark of Medicaid.

One way states raise funds for their share of Medicaid spending is by having hospitals or nursing homes pay the provider taxes. States often reimburse providers through the additional federal money.

Blase acknowledges that the provider taxes used by states for federal money — which Paragon has called “money laundering” — are legal. He said the practice as a “tax” is misleading because providers benefit financially from it.

“Money laundering is the best term we can think of for the schemes and states to obtain reimbursement of artificial federal expenditures that benefit 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 for low-income people. She noted that most states with provider taxes are at least partially controlled by Republicans.

Alker rejected the idea that increased funding to expand enrollment is “discrimination.” The ACA included the higher rates to cover more low-income enrollees because that was the only way states could afford it, she said.

Without giving a specific example, Blase said advocates said cuts would "leave people dying on the streets."

During a brief January funding call for Medicaid providers in January, Sen. Ron Wyden of Oregon, the top Democrat on the Senate Finance Committee, said, "This is a blatant attempt to remove health insurance from millions of Americans overnight and kill people."

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