Who Uses Medicaid?

Last week, the Senate revealed the Better Care Reconciliation Act (BCRA), the Senate’s proposal to repeal and replace — technically, BRCA doesn’t do either — the Affordable Care Act (ACA). The bill, drafted in private by a group of 13 Republican senators, was immediately met with disapproval, causing Sen. Mitch McConnell of Kentucky to delay the BCRA vote until after the July 4th holiday recess.

Side note: When senators actually want a bill to pass, and want to get the public on their side, they give it a good and easy-to-remember acronym — think the PATRIOT Act or the REINS Act. BRCA is not a good acronym.

One of the biggest points of contention with BRCA is the $772 billion in cuts to Medicaid, the private-public program that provides insurance to the poor and disabled. Dismantling Medicaid has been a pillar of the Republican platform since the legislation passed in 1965, and this is the closest they’ve come to accomplishing that goal. Since there is a very real chance BRCA could pass in some form, the question to ask is: Who will be most affected by a defunded Medicaid?

(Full disclosure: I have family who rely on Medicaid, and I work for an insurance company that supplies Medicaid to 14 states. The opinions expressed herein are my own and do not represent my employer. Corporations aren’t people and do not have opinions.)

Judging by race and ethnicity, which is how the government categorizes usage, no one demographic makes up a majority of the Medicaid population. (By gender, women far exceed men for Medicaid usage, 58 percent to 41 percent.) White Americans are the single largest racial group using the program, accounting for 41 percent of all members in 2012, the last year race data was available, according to the Centers for Disease Control and Prevention. Whites take up an even larger percent of Medicaid dollars, receiving 51.8 percent of the program’s funds.

The numbers are more telling on a state-by-state basis. White Americans make up the largest group of Medicaid users in 38 states, and are a 50 percent or greater majority in 25 of them. Those numbers gain a little more perspective when looked at through a political lens: of the 38 states where white people make up a majority of Medicaid members, 24 went for Trump in 2016, and Republicans took 20 of the 25 states where whites are more than half of the Medicaid population. States that voted for Trump also have about 2 million more Medicaid members than blue states.

Red: Whites make up the largest group of Medicaid members. *Whites make up less than 50 percent of Medicaid members. Maine’s 2nd district not shown as the majority of the state voted Democrat.

Repealing Obamacare was perhaps the biggest part of the Republican platform in 2016, which makes little sense when two-thirds of red states depend on Medicaid, often heavily — Kentucky, home state of BRCA author Sen. McConnell, has as much as 33 percent of its citizens on the program. Medicaid is targeted to help people in economically depressed areas, which include a majority of states in the Rust Belt and Sun Belt that voted for Trump. So, why do conservatives want to repeal a program upon which they depend?

For Republican pols, BRCA gives them three distinct wins: it lets them fulfill their campaign promises to replace Obamacare; it reduces the size of a government program in favor of the free market; and it gives a tax cut to the wealthiest Americans. As long as they aren’t up for re-election in 2018 in a state that Clinton won (only two are), it’s an easy choice.

Voters’ reasons are a little more complex and varied. First, most Americans don’t really understand what Medicaid is: only 14 percent of Americans understand the most basic insurance concepts, let alone the complexities of public-private partnerships. Second, in several states, Medicaid goes by a different name — it’s called Healthy Louisiana in the Bayou state and Kentucky Health in Sen. McConnell’s home, for example — so many Americans who receive Medicaid may not even realize it. This is a very under-reported wrinkle in the program, and one I have encountered repeatedly in my work.

Finally, the elephant in the room: the racial component. Republicans have long slandered Medicaid as an “entitlement program,” a dog whistle for conservatives that says “this helps brown and black people.” It’s hard to quantify what effect this has, but it’s easy to hear it in the language used to talk about Medicaid and Obamacare. Any reference to “entitlement,” “redistribution” and the like send a crystal clear message to a certain wing of the Republican base. That these voters would destroy something they use, cutting off their nose to spite their face, is no surprise — it's the same behavior that led to Trump’s election.

So who gets Medicaid? If you had to put a face to the population, it would be a white woman in a red hat. That woman needs Medicaid more than she may realize. Getting rid of it hurts her, hurts her neighbors, and hurts her country. Most opposition to Medicaid is based on ignorance — either racism or a lack of understanding — meaning education is the best tool we can use to save the program. Unfortunately, with BRCA slated for a vote as early as next week, time is short. If you want to make a difference, contact your senator today.

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