Confusion muddies the debate over possible Medicaid cuts

Some Americans who rely on Medicaid to pay for their health care don't realize their insurance is funded by that very program, which congressional Republicans are looking to shrink.

One reason is that state programs aren't always called "Medicaid." Many states have rebranded their programs with consumer-friendly names such as SoonerCare in Oklahoma, Apple Health in Washington, Medi-Cal in California or TennCare in Tennessee. In Missouri, it's MO HealthNet and MO HealthNet for Kids.

And nearly all states now use private insurance companies such as UnitedHealth or Blue Cross Blue Shield to run their Medicaid programs. That means Medicaid enrollees may hold an insurance card and paperwork with the name of a commercial insurance company.

"We toss around terms like 'Medicaid,' but we see so many of our patients not having [insurance cards or] anything that describes or uses the word 'Medicaid,'" said Dr. Adam Brown, a Washington, D.C. emergency physician and founder of a health care strategy firm.

"People oftentimes do not realize either that they have it, or know the value of what it does."

Medicaid is the health insurance program for people with low incomes or certain disabilities. About 72 million people, or about a fifth of all the people living in the United States, are enrolled. It operates with state and federal funding, but every state has the freedom to choose how to run its program, within federal rules.

As a result, Medicaid is a sprawling patchwork of programs that can confuse lawmakers and even top health officials, not to mention the average beneficiary. Robert F. Kennedy Jr., secretary of the U.S. Department of Health and Human Services, incorrectly described basic elements of Medicaid and seemed to confuse it with Medicare during his confirmation hearing before Congress in January.

Republicans in Congress are considering proposals to slash hundreds of billions of dollars from federal Medicaid funding as they look to offset trillions in tax cuts proposed by President Donald Trump. The specifics of the Medicaid cuts are still being hammered out. But any reductions to federal Medicaid spending would shift those costs to states, which would likely be forced to end services or cut coverage for certain groups of people.

"Part of the problem is when we hear people talk on television or hear lawmakers talk, there are many people that don't make the connection that they themselves are on [Medicaid] or that their hospital is very much dependent upon the dollars that come from Medicaid," said Brown.

"Calling it one thing and branding it something very different, that makes it challenging for people to understand the connection or the value in the product that they actually have."

About three in four people who have Medicaid are enrolled in managed care organizations (MCOs), according to the latest national data. Most of these are private plans operated by companies such as UnitedHealth Group and Centene. But the branding from these companies can distance recipients from the fact that their care is paid for with public funds.

When Brown worked in emergency medicine, he had many patients who had insurance through Medicaid.

"There were times they would show me their card and it would have commercial branding, like a Blue Cross Blue Shield," he said. But as they talked, "I noticed there was a lack of understanding that they were on a Medicaid-supported or state/federal-supported program."

Millions of people who are enrolled in Medicaid mistakenly believe they're uninsured, Dr. Ben Sommers, a Harvard health economist and physician, told Stateline.

"It is a long-standing issue that got worse during the pandemic," he said.

He and fellow researchers found that the gap between the number of people who have Medicaid and the number who think they have it jumped during the pandemic, to about 18.5 million people. This was due to a lack of public understanding about a COVID-era rule that granted continuous Medicaid coverage to people without requiring them to re-enroll, researchers found.

Sommers expects the gap will eventually return to pre-pandemic levels, or nearly 6 million people.

"That's still a lot of people who don't think they're in Medicaid but who are," he said.

There are also some uninsured people who enroll in Medicaid when they show up at an emergency room or clinic needing care. Most providers will check for Medicaid eligibility if a person doesn't have another form of insurance. People who become Medicaid beneficiaries that way may not realize it's Medicaid paying for their care, Sommers said.

Public debate

Physicians, public health experts and advocates worry that the confusion over Medicaid is affecting public debate over funding cuts.

From a public health perspective, Sommers said, "It's not a huge problem if people think they have one type of insurance and misclassify it, as long as they're getting care."

"Politically, it can be tricky if people don't recognize they have Medicaid and they're trying to weigh in on policies that affect Medicaid."

Conservatives have long argued for reducing the reach of Medicaid. They say the program is too expensive and that its expansion under the Affordable Care Act, also known as Obamacare, diverts too much money toward able-bodied adults and away from the more vulnerable populations it was originally intended to help.

But Medicaid is extremely popular. More than three in four people view Medicaid favorably, including nearly two-thirds of Republicans, according to a January tracking poll from KFF.

In focus groups conducted in January by KFF, no Trump voters and few Harris voters said they were aware of proposals to cut federal Medicaid dollars, and some Trump voters said they didn't think Trump would follow through on the cuts.

Making the connection

Brown said that despite confusion, most Medicaid patients he encountered were aware their insurance came through a government program.

But he said it can still be hard for people — including those with private insurance — to make the connection between Medicaid funding cuts and their local hospitals or other services.

"We oftentimes frame this as 'People will lose their health insurance,' and that is true," Brown said. But "the constituencies affected are not just the people who have Medicaid."

Less funding for Medicaid, or an increase in the number of people without insurance, would harm people with any kind of insurance, he said. It could lead to longer wait times at hospitals, fewer services offered and, in some cases, hospital closures.

"One of the important parts about democracy is people being educated about what their representatives are voting for or against, and also how to advocate for yourself," Brown said. "If you don't fundamentally understand or fully grasp the benefits you have, then it's harder to advocate."

Stateline is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Stateline maintains editorial independence. Contact Editor Scott S. Greenberger for questions: [email protected].

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