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Pulling It Together: A Public Opinion Surprise

Medicaid is the nation’s primary health insurance program for low-income people and people with disabilities, covering more than 60 million people this year.  And it’s about to get a lot of attention: it’s likely to be a prime target for spending reductions by “deficit hawks” in debate over the budget; governors are arguing that federal rules requiring them to maintain coverage under Medicaid tie their hands at a time when they are trying to crawl out of the recession to balance their budgets; and the health reform law expands Medicaid coverage to all of the poor starting in 2014.

If you listen to the inside debate you would think Medicaid is America’s most unpopular program. Conservatives don’t like Medicaid on ideological grounds; it’s a government entitlement program.  Providers complain about the program’s reimbursement rates.  And liberals have long complained about the program’s limitations, especially the gaps in whom Medicaid covers and the large variations in coverage among states.  With its joint federal-state financing and welfare-linked heritage, Medicaid is treated as fundamentally different than the two other big entitlement programs — Social Security and Medicare — and thought to have dramatically less public support.

It was against this background that one of our recent polls produced a real surprise. It turns out that the insider’s view of Medicaid is not the public’s view at all.  While not viewed as favorably as Social Security or Medicare, Medicaid is actually surprisingly popular with the American people, and they resist the idea of making big cuts to the program.

When we asked in our poll which programs the public was willing to see cut by Congress to reduce the deficit, no surprise, only 8% were willing to see “major reductions” in Social Security or Medicare. But only 13% were willing to see major reductions in Medicaid, the same percentage as for public education.  Sixty-four percent supported “no reductions” at all in Social Security as a way to reduce the deficit, 56% in Medicare, and 47% in Medicaid, hardly the mark of an unpopular program.  Forty-six percent of independents and a little more than a third (35%) of Republicans said they would “not support any reductions at all” in Medicaid to reduce the deficit.  The findings about support for major reductions are noteworthy because policy proposals such as capping the rate of increase in spending on major health programs and some Medicaid block grant proposals made to reduce federal spending would almost certainly entail major cuts.

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We got some clue about why Medicaid is more popular than the debate about the program might suggest from another question.  Fifty-nine percent of the American people said Medicaid was either “very important” to them or their families (39%) or “somewhat important” (20%).

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In health policy circles it has long been thought that Medicaid’s primary political protection comes from the vital long-term care and acute care services it provides to its elderly and disabled beneficiaries (and the political clout of the providers who serve them), even though these groups makeup a minority of Medicaid beneficiaries.  Those of us who have overseen Medicaid programs at the state level can certainly attest to the influence nursing homes and the disability community have in state legislatures. But with Medicaid now touching 69.5 million Americans in 2011, according to the Congressional Budget Office, and many more over time as beneficiaries and their family members and friends move in and out of the program, a more likely explanation for the program’s surprising support in our poll is simply that it has become more ingrained in the fabric of American life than has been generally realized.  State programs rebranding Medicaid in more popular ways in several states may also have helped change the program’s image with thegeneral public.  Medicaid now covers nearly one in three children, with the recession driving many previously middle-income children onto the program,providing coverage their parents no doubt value.

I have never taken the position that policymakers should follow the polls; they are one factor in a much larger equation. There is also no question that the public wants the deficit addressed, even if they flinch at cutting popular programs. Sixty-four percent ofthe public told us in the same poll that they were “very concerned”about the federal deficit (yes, the American people are fully capable ofembracing conflicting priorities such as reducing thedeficit and preserving popular programs, and that is a challenge forpolicymakers).

No doubt poll results on all the deficit reduction proposals will shift as a real debate breaks out and the public hears the arguments (and the spin).  Public reaction to proposals to cut programs to balance the federal budget could also be quite different from reactions to proposals for cuts at the state level if savings from state budget cuts are used for popular purposes other than general budget balancing, such as education.  We will examine the public’s views on changes in Medicaid and other public programs and proposed spending reductions more fully in upcoming polls.  But for now, with major proposals beginning to be discussed that could fundamentally change the Medicaid program and its role as a foundation for coverage expansion under health reform, it seems important to at least note these preliminary findings. They suggest that the conventional wisdom that Medicaid is an unpopular program that would be much easier to cut or change than the other big public programs could be exaggerated if not simply wrong.