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Analysis: Gubernatorial candidates describe Medicaid as health care or welfare, depending on their stance

Sunday, August 3, 2008 | 6:28 p.m. CDT; updated 11:46 a.m. CDT, Thursday, September 3, 2009

 JEFFERSON CITY - Voters take your pick: health care or welfare?

One sounds like something everyone should have. The other sounds like something demeaning to need.

Missouri's 2008 general elections figure to be a linguistic battleground as politicians describe efforts to cut, restore and expand Missouri's Medicaid program.

Described as health care, it sounds easier to support. Described as welfare, it sounds easier to curtail.

Republican Gov. Matt Blunt and the GOP-led Legislature cut eligibility for Medicaid in 2005 while asserting it had grown too costly to sustain. The top Republican contenders to succeed Blunt in Tuesday's gubernatorial primaries - Kenny Hulshof and Sarah Steelman - generally defend that decision.

The likely Democratic gubernatorial nominee, Jay Nixon, wants to restore the Medicaid cuts.

Nixon recently announced a plan "to fix Missouri's broken health care system."

A Republican triumvirate of budget writers - the Senate, House and executive branch budget directors - responded with a denouncement of Nixon's "expansion of the welfare system."

Their word choices were intentional. And both descriptions were technically correct.

As authorized by the federal government, each state runs its own version of Medicaid, which pays for health care for certain low-income people. In Missouri, the program recently was renamed as MO HealthNet.

Medicaid's roughly 600-word overview on the Web site of the federal Centers for Medicare and Medicaid Services includes no mention of a "welfare" program.

Instead, its description begins like this: "Good health is important to everyone. If you can't afford to pay for medical care right now, Medicaid can make it possible for you to get the care that you need so that you can get healthy - and stay healthy."

That certainly sounds like a health care program.

But then there is the dictionary definition of welfare: "aid in the form of money or necessities for those in need."

Considering health care as a human necessity and considering that Medicaid is provided to those in financial need, it also sounds like a form of welfare

There was a time when Medicaid definitely was grouped with welfare.

Welfare, in its most common understanding, was the word used to describe the cash payments provided to the poor through the Aid to Families with Dependent Children program. Anyone receiving welfare payments qualified for Medicaid.

But welfare developed a reputation as a lazy entitlement. So in what's commonly referred to as "welfare reform," Congress and President Clinton in 1996 revamped the old AFDC program with new work requirements and renamed it as Temporary Assistance for Needy Families. They also severed the automatic link between Medicaid and cash welfare payments. The result was that millions of more children and parents became eligible for Medicaid without necessarily qualifying for cash welfare payments.

So people can receive health coverage through Medicaid without "being on welfare."

Missouri's Medicaid rolls now include some children from families earning up to three times the federal poverty level - $63,600 for a family of four - through what's called the State Children's Health Insurance Program. The title uses the words "health insurance," not "welfare."

Nixon has proposed to expand that eligibility threshold by allowing families earning more than that to buy in to the government-run health-care coverage.

In a news conference criticizing Nixon's plan as too costly, Senate Appropriations Committee Chairman Gary Nodler, House Budget Committee Chairman Allen Icet and Blunt's Administration Commissioner Larry Schepker each described it as "welfare."

Asked about their word choice, they defined welfare as a subset of health care.

"Health care is a topic that is broad. It covers hospitals and clinics and doctors and nurses and dentists and chiropractors and osteopaths, and it involves public and private sources of insurance and assistance," said Nodler, R-Joplin. "What this proposal deals with is the welfare system, and particularly the health care aspects of the welfare system."

Describing Medicaid as welfare communicates a different - and more proper - message to the public than merely calling it health care, Icet added.

"We're talking about people who are not paying, for the most part, for their own health care costs. But we as taxpayers are paying that cost," said Icet, R-Wildwood.

The Republican gubernatorial candidates generally have used more gentle words while conveying essentially the same message.

In campaigns speeches, Hulshof routinely refers to the period before the 2005 Medicaid cuts as a time when "there were a million Missourians on public assistance." He stresses: "Almost one-in-five Missourians on public assistance."

Asked separately if their candidates consider Medicaid to be welfare, spokesmen for Hulshof and Steelman replied with almost identical language.

"She views it as a safety net for the truly needy," said Steelman spokesman Spence Jackson.

"A safety net for the most vulnerable Missourians is ideally how it should be used," said Hulshof spokesman Scott Baker.

Nixon spokesman Oren Shur said the Democratic gubernatorial candidate is fine with describing Medicaid as "health care," "health coverage" or "health insurance," but certainly not "welfare."

"When our opponents callously describe health care as ‘welfare,' they are insulting thousands of veterans, seniors and families across our state," Shur said.

 


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