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How Democrats Can Save Medicaid For Good

Despite becoming a middle-class entitlement, Republicans still aren’t scared to gut the program. Why?

Win McNamee/Getty Images

After a period of cautious optimism that the American Health Care Act was dead on arrival in the Senate, the upper chamber is inching closer to making the nightmare of Trumpcare a reality. As Sarah Kliff reported on Monday in Vox, moderate Republicans are starting to drop their objections to rolling back the Medicaid expansion that took place under Obamacare, meaning that the Senate bill is lining up with the House’s extremely unpopular bid to uninsure some 23 million people. No one outside the Senate knows what exactly is in the bill—sound familiar?—and Republicans do not intend to make its draft public, suggesting that the GOP is trying to gut Medicaid in the dead of night.

All this secrecy indicates that Senate Republicans understand that hobbling Medicaid would be politically damaging. But not so damaging that they won’t go through with it anyway. There had been a growing sense that Medicaid—along with coverage for people with preexisting conditions—had become a new third rail in American politics, liable to torch anyone who dared touch it. But as the GOP-controlled Senate rushes to pass its version of health care reform before the July 4 break, without holding any hearings, both grassroots organizations and Democrats in Congress will not only have to figure out a way to break the bill, but also to frame Medicaid as an entitlement that can’t be compromised without inviting devastating political harm. To that end, they can draw lessons from the last time that Republicans came close to radically overhauling the program.

The GOP’s attacks against Medicaid, which was created to serve the poor and the disabled, are not new. The closest attempt was in 1995, when House Speaker Newt Gingrich tried to push through a bill that would have block-granted the program. (The AHCA offers states that option, which would result in severe benefits cuts.) But President Bill Clinton eventually saved Medicaid from the Republican plan by reframing it as a middle-class entitlement. During a speech he made in July of that year, Clinton compared the program to Medicare, the more popular universal program for the elderly, and pointed out the ways in which Medicaid was helping middle-class elderly Americans:

In 1965, the legislation which created Medicare also created Medicaid. A lot of Americans think it’s just a program for poor people. Well, it did provide desperately needed care for poor children and their mothers, but it also provided more care for older and disabled Americans, especially long-term care. Two-thirds of the Medicaid budget goes for older Americans and disabled citizens. Without Medicaid, middle-class families struggling to pay their own bills and raise and educate their children could face nursing home bills for their parents averaging $38,000 a year.

Clinton’s recasting of Medicaid allowed him to take a firm line against Republican attacks. As James A. Morone, professor of political science at Brown University, recently told the New York Times, Clinton was “the first Democrat to start calling Medicaid one of ‘our programs.’” Clinton’s rhetoric ended up reverberating in media coverage of the program. And, later in his term, Clinton was able to expand the program for millions of kids through the Children’s Health Insurance Program (CHIP), which covered children whose parents made too much to qualify for Medicaid.

But Clinton’s fight for Medicaid came at the expense of another program for the poor: welfare. Originally, Republicans tied Medicaid and welfare reform into a single bill that Clinton refused to sign. It wasn’t until the two were decoupled that Clinton passed the now-infamous 1996 bill that block-granted welfare, resulting in a huge rise in the extreme poor.

As Peter Edelman, who resigned in protest from Clinton’s Department of Health and Human Services, wrote at the time, “Large numbers of middle-income people had elderly parents in nursing homes whose bills were paid by Medicaid—to say nothing of the potential impact on hospitals, physicians, and the nursing homes themselves, all of which groups have substantial political clout. Welfare had no politically powerful constituency that would be hurt by conversion to block grants.” And as Erik Voeten, political scientist at Georgetown University, has pointed out, “Clinton went to great lengths in 1995 to distinguish Medicaid from welfare” by focusing on how the former benefited “hard-working, middle-class taxpayers.”

To save Medicaid, Clinton sacrificed welfare, using it as foil to show that Medicaid was a benefit for the “deserving” middle class. Today, however, it is impossible to deny that Medicaid serves the middle class. It now covers 74 million people and is our nation’s biggest health care program. The Medicaid expansion was arguably the biggest success of Obamacare—the program is, in fact, the heart of the law. Of the estimated 20 million people who were newly insured after Obamacare passed, 14 million were from Medicaid enrollment. (The Kaiser Family Foundation estimates that around 11 million of these enrollees were newly eligible for Medicaid. The disparity is due to the “welcome mat effect” of increased publicity and parents who became newly eligible but may not have known that their kids already were.)

Medicaid has grown enormously since its inception, covering 21 percent of the population, up from 2 percent in 1966. It has been especially beneficial for children: Taken together, Medicaid and CHIP cover one in three kids. Meanwhile, 60 percent of nursing home patients are funded by Medicaid. Perhaps most importantly, almost two-thirds of Americans are personally familiar with the program, having either received Medicaid themselves or known a friend or a family member who has.

Growing enrollment is why the program has been politically problematic for repeal-and-replace Republicans, many of whom represent states that expanded Medicaid during the Obama years. According to polling by the Kaiser Family Foundation, people who report no personal experience with Medicaid “are more likely to say Medicaid is not a very important government program by more than 15 percentage points.” But more and more people do have personal experience with the program, especially after Obamacare. According to more recent polling in February, two-thirds of Americans said they preferred Medicaid funding to continue as is. The Medicaid state expansions are also extremely popular: 95 percent of Democrats, 84 percent of independents, and 69 percent of Republicans said it was important to ensure that any Obamacare replacement continue to allow expansion states to receive federal funding.

If casting Medicaid as a middle-class entitlement saved it in the 1990s, that message only has greater resonance today. Democrats should continue to push back on Republican health care efforts by hammering home the fact that tons of people benefit from the program. As Minority Leader Chuck Schumer stated in May, “Medicaid has always benefitted the poor. That’s a good thing. But I remind my colleagues that it has increasingly become a middle-class program.”

But Democrats should be careful to not repeat Clinton’s mistakes. While tying Medicaid to the middle class is a politically powerful tactic, Medicaid’s ultimate value can’t be predicated on the fact that it’s become a middle-class program. If this were to happen, Democrats would fall into the trap of dividing “deserving” recipients from “undeserving” ones. The middle and lower-income classes are not the separate entities that we often believe them to be: Most people in this country will have lived through a spell of poverty before the end of their lives. Rhetoric separating Medicaid from other programs for the poor will also contribute to the vilification of benefits like food stamps and welfare, which President Donald Trump is also threatening to cut.

The lesson of Medicare and Social Security is that universal benefits programs are protected because they are universal. Medicaid is defined by income thresholds, but it can also be dressed in the language of universal coverage, which is the end goal for the Democratic Party. Democrats should take advantage of the strength of increased Medicaid enrollment to portray it as a benefit that unites the interests of poor, low-income, and middle-class constituents. By casting Medicaid as a stepping stone towards universal coverage, and pointing out how Trump and Republicans are betraying the American people by weakening the program, Democrats can protect Medicaid and build on the gains it has made.