Medicaid as a middle-class entitlement

September 8, 2012

Eric Patashnik notices a key strategic move that former president Bill Clinton employed in his Democratic National Convention speech: He recast Medicaid as a program for the middle class, rather than for the welfare population.

"A lot of folks don't know it, but nearly two-thirds of Medicaid is spent on nursing home care for Medicare seniors who are eligible for Medicaid," Clinton told the crowd. "A lot of that money is also spent to help people with disabilities, a lot of middle-class families whose kids have Down syndrome or autism or other severe conditions."

Patashnik has previously done research that looked at Clinton's Medicaid rhetoric, and he says this isn't an isolated take: Clinton has put no small effort into recasting Medicaid as a program that serves the middle class. In 1995, when he faced off against House Republicans over a government shutdown, he regularly grouped Medicaid with Medicare, environment and education -- government programs not tethered to income levels.

The media changed how the way they talked about Medicaid during Clinton's presidency, too. Patashnik did one study, back in 2003, in which he combed through newspaper articles to see how the entitlement program was characterized. Between 1981 and 1995, descriptions changed a lot. Here's his chart, with data on 81 news articles:

Is Clinton right to describe Medicaid as a middle-class program? For the adults it serves, not really: Most states cap Medicaid eligibility for parents well below the poverty line. If an adult does not have children, he or she is usually not eligible at all. Only eight states offer Medicaid coverage to single adults.

But if you look at two other populations -- children and the elderly -- it does indeed serve a middle class demographic.

The Children's Health Insurance Program, created in 1997, is responsible for bringing Medicaid to middle-class kids Under CHIP, some states cover children up to 300 percent of the poverty line -- a $60,520 income for a family of four.

The other middle-class population in Medicaid tends to be the elderly. Since Medicare does not cover long-term care, such as the care provided in nursing facilities, Medicaid often picks up the bill for such services. Nina Bernstein has this excellent article on how Medicaid often becomes the safety net for elderly patients with complex conditions who  ultimately exhaust their assets on medical treatment.

So it's not just rhetoric: Medicaid does indeed serve a middle-class population, just as Clinton has persuaded us over the past few decades.

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Suzy Khimm | September 8, 2012