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THE WORD GAMES THAT ENABLE MEDICAID CUTS  
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Thom Walsh
June 23, 2025
The American Prospect
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_ We don’t call it Medicaid in many states, and we use euphemisms
for what are in reality cuts. That endangers the system, a health care
regulator writes. _

Over the years, many states have rebranded their Medicaid programs to
distance them from national politics; as a result, many recipients do
not realize they are on Medicaid., Rich Pedroncelli/AP Photo

 

_The following is a guest post for the “Trump’s Beautiful
Disaster” newsletter by Thom Walsh, a member of the Green Mountain
Care Board, Vermont’s regulatory system for health care__._

Earlier this month, the Vermont Association of Hospitals and Health
Systems warned
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that the Senate’s budget bill could cost Vermont hospitals more than
$1.7 billion over five years. That’s in a state where many hospitals
are already operating at a loss. The threat isn’t just to patients.
It’s to jobs, local economies, and community anchors.

Vermont isn’t alone, and neither is Congress in savaging the health
care system. In Missouri, over 30,000 children lost Medicaid coverage
in 2023—many due to paperwork problems or system delays. In
Mississippi, lawmakers advanced a bill to overhaul Medicaid
eligibility systems, despite the state’s limited administrative
capacity. Across the country, these changes are pitched as efficiency
or modernization. But their effects are cumulative—and massive.

What’s happening to Medicaid isn’t overt. It’s incremental and
strategic. The Senate’s latest proposal, far from softening the blow
from the House’s version, includes a cap on provider taxes,
reinstatement of co-pays, and expansion of work requirements for
parents
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These measures aren’t labeled as Medicaid cuts, but their purpose
and effect are exactly that. And because they’re framed in the
language of efficiency and fiscal discipline, they often escape public
notice. That’s by design.

REBRANDED, REFRAMED, AND REDUCED

The reality is that many people don’t know they’re on Medicaid
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Over the years, many states have rebranded the program to distance it
from national politics. Oklahoma calls it SoonerCare. Arkansas uses
ARHOME. Connecticut’s program is HUSKY Health. Tennessee has
TennCare. These names make Medicaid more palatable locally—but also
more vulnerable. When coverage is lost or eligibility is tightened,
beneficiaries often don’t realize what they’re losing. The
branding creates political insulation.

In Arkansas, polling shows broad support for the coverage ARHOME
provides—but far less support for “Medicaid” as a term. That
disconnect lets lawmakers publicly praise ARHOME while voting to
restrict its eligibility or quietly reduce oversight. The rebrand
becomes a shield, obscuring the source of the program’s success and
making it harder to trace the consequences of its decline.

At the same time, federal and state policymakers have developed a
policy vocabulary built to obscure. “Flexibility.” “Eligibility
integrity.” “Provider alignment.” “Cost-sharing.” Behind
these phrases lie real reductions in access, funding, and system
stability. As these reductions compound, so does the gap between what
the public thinks Medicaid is and what it actually does.

Expanded work requirements are among the most effective tools in this
stealth strategy. The Senate proposal extends work requirements to
parents of school-aged children. At face value, the policy sounds
plausible—who could oppose encouraging work? But experience tells a
different story.

In Arkansas’s short-lived 2018 Medicaid work requirement pilot
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18,000 people lost coverage. Most were working. They just couldn’t
keep up with confusing reporting requirements, poor internet access,
or inconsistent job schedules. In many cases, they didn’t even know
their coverage was at risk. The system wasn’t built to promote work.
It was built to reduce enrollment.

We’ve seen through the years that administrative “friction” is a
powerful policy lever. Churn replaces continuity. Preventive care is
delayed. Diagnoses are missed. Parents lose access, and children
follow. Hospitals, schools, and public-health departments are left to
pick up the pieces.

According to the Center on Budget and Policy Priorities
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red tape has become a primary mechanism for reducing enrollment. For
example, when states froze automatic redeterminations during COVID,
coverage rates stabilized. But now, with the “continuous coverage”
freeze lifted, disenrollment is rising, with cuts to the program
smuggled in under the guise of “program modernization.”

The Centers for Medicare & Medicaid Services found that more than 70
percent of children losing coverage during the unwinding of the COVID
continuous coverage requirement were removed not because they were
ineligible, but because of missed mail, incorrect forms, or
hard-to-navigate renewal systems. These breakdowns aren’t
accidental. They’re a feature of a system designed to deter
participation.

MEDICAID IS INFRASTRUCTURE

Medicaid is not a marginal welfare benefit. It’s infrastructure.
It’s the connective tissue of the U.S. health care system. Its
footprint is wide, but its visibility is low. That’s what makes it
so easy to cut, and so dangerous to weaken.

Many beneficiaries don’t realize that the programs they rely
on—like home health services for an aging parent, behavioral health
access, or school-based mental health support—are funded through
Medicaid. Many don’t know that Medicaid pays for 41 percent of all
births, and supports over 30 percent of all behavioral health funding.
Many are unaware that it is the largest payer for long-term care.

Medicaid keeps hospitals open, stabilizes state budgets and individual
insurance premiums, supports long-term care systems, and makes
behavioral health treatment possible in underserved communities.

Like clean water or working roads, we don’t talk about Medicaid when
it works. But we will notice when it fails. And when Medicaid is
quietly eroded, it doesn’t take long for the system to show cracks.

Hospitals are among the first to feel it. Especially in rural areas,
where margins are already thin, even modest changes in reimbursement
or enrollment can be catastrophic. According to a report from the
Center for Healthcare Quality and Payment Reform
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over 25 percent of rural hospitals are at risk of closure nationwide,
and in 11 states, that number rises to 50 percent.

Data from KFF
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shows that the hospitals at most significant risk of failure are in
red states that have refused to expand Medicaid. Negative margins are
more common among rural hospitals in the most remote areas. That means
cuts to Medicaid won’t just affect outliers—they’ll hit the most
vulnerable institutions in the least-protected communities.

EVERYONE PAYS

When these facilities close, the consequences ripple outward: job
losses, longer emergency response times, reduced access to prenatal
care, and fewer behavioral health services. And the ripple effects
don’t end at the hospital doors.

When providers face revenue shortfalls, they will raise prices charged
to commercial payers, if they have the market power to do so. And if
there are fewer hospitals serving patients, that market power will
rise. That means higher premiums, deductibles, and cost-sharing.
Employers struggle to offer affordable plans. Small businesses shrink
or close entirely. Families tighten their budgets to absorb the
difference. Some go bankrupt
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In this way, Medicaid isn’t just a safety net for the poor—it’s
an invisible subsidy for everyone. When it shrinks, costs don’t
disappear. They move to households, employers, local governments,
school systems, ERs, jails. Everyone pays.

The people most likely to bear the burden are often the least likely
to recognize the source. Because the cuts are obscured—by branding,
language, and bureaucracy—the link between cause and consequence is
broken.

PUBLIC WILL, POLITICAL EVASION

Earlier this month, a survey commissioned by the Milbank Memorial Fund
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found that 75 percent of Americans want Medicaid funding maintained or
increased. Two-thirds reported a personal connection to the program.
More than half said they’d be willing to contact their elected
officials to oppose cuts.

But the cuts continue, precisely because they are masked. Provider tax
caps sound like technical adjustments. Work requirements sound like
incentives. Reduced enrollment eligibility sounds like accountability.
None of these terms reveal the outcome: fewer people covered, less
financial stability for providers, and higher costs for the rest of
us.

Even in news coverage, these proposals are seldom framed as Medicaid
cuts. This failure in framing complicates public response and makes it
more challenging for advocates to organize.

WHAT WE CAN DO

How can we prevent this damage? Step one: linguistic clarity. Provider
tax caps are Medicaid cuts. Reinstated co-pays are Medicaid cuts. Work
requirements are Medicaid cuts. Labeling matters. If we can’t name
what’s happening, we can’t build opposition—or propose
alternatives.

Step two: reclaim Medicaid’s identity. SoonerCare is Medicaid.
TennCare is Medicaid. HUSKY Health is Medicaid. “Dr. Dynasaur”
refers to Medicaid-funded health coverage for children and teens in my
state of Vermont. When these programs are cut, people suffer—even if
they don’t know what to call it.

Step three: reframing the public conversation. Medicaid is not just
for someone else; it protects us all—whether through our hospitals,
family caregivers, or insurance rates. To defend it, we must start
discussing it for what it truly is: a public good, an economic
stabilizer, and a moral commitment.

Step four: organizing policy response. That means requiring states to
disclose coverage impact estimates when pursuing administrative
changes. It means restoring federal guardrails that prevent states
from using administrative burdens as a backdoor cut. It means tracking
rebranded programs and holding them accountable for transparency and
continuity.

When public programs become unrecognizable, they become indefensible.
Medicaid’s survival relies not only on budgets but also on public
understanding. That makes language—not just legislation—the front
line in this battle.

Medicaid’s dismantling isn’t occurring by accident—it’s
happening by design. However, naming it for what it is—cutting
Medicaid—is the first step in resisting. By calling these budgetary
tweaks and administrative hurdles by their true names, we empower
people and policymakers to take action. We must ensure recognition,
transparency, and the civic infrastructure that connects Medicaid to
the lives it impacts.

Many hoped that after the House passed a proposal for deep Medicaid
cuts, the Senate would intervene to soften the blow, protect the most
vulnerable, and stabilize a fractured system. But no one is coming to
save Medicaid—not unless the public sees these policies for what
they are and demands something different.

Thom Walsh, Ph.D., M.S., is a member of Vermont’s health care
regulatory body, the Green Mountain Care Board, and a lecturer at
Dartmouth’s Geisel School of Medicine and Tuck School of Business.

* Medicaid; State Health Programs; Hospitals; Budget Cuts;
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