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You've probably heard that millions could lose Medicaid coverage because of the budget bill Congress has passed. But some of the more than 70 million Americans who have it may not even know that they're actually on Medicaid. Alex Olgin explains.

ALEX OLGIN, BYLINE: Priscilla Easterling spends a lot of time explaining to people in Kentucky what Medicaid is and how it helps people in her role at patient advocacy group Kentucky Voices for Health.

PRISCILLA EASTERLING: We have these great I Heart Medicaid shirts that we have spread far and wide because we really understand Medicaid is an incredibly important safety net for Kentucky.

OLGIN: A third of Kentucky's 4.5 million people are covered by the joint federal-state health care program, but many don't even know it. Easterling remembers a man that she met at a health fair. He was describing how his parents had a program that wasn't explicitly called Medicaid. The man did not like hearing that's actually what it was.

EASTERLING: He just blew up. He started yelling. He started screaming about no one in his family was ever using Medicaid. That's for poor people. That's not for us.

OLGIN: Easterling says she runs into this confusion all the time, and it's understandable. The federal government calls it Medicaid, but several states renamed their programs.

ADRIANNA MCINTYRE: In Massachusetts, it's MassHealth. In Texas, it's Texas STAR.

OLGIN: That's Adrianna McIntyre, professor of health policy and politics at the Harvard T.H. Chan School of Public Health. She says many states did this to reduce stigma and make it feel closer to home. McIntyre suspected that the rebrands might make the program more popular, especially among Republican voters, but her research surprised her.

MCINTYRE: What we found is that it didn't actually increase favorability, and partisanship didn't matter in that regard. Instead was that people just were confused, were more likely to be confused if you used the state-specific program name.

OLGIN: To add to this confusion, many people with Medicaid actually have insurance cards that say Centene, Aetna or UnitedHealthcare. That's because 41 states privatized their programs. That means these insurers pay the bills and handle all the details. McIntyre says she worries that all these layers mean that people have no idea that budget discussions in Washington could threaten their coverage. This happened over the last few years with the last round of changes to Medicaid post-pandemic.

MCINTYRE: The most frequent way people found out was they went to go fill a prescription and they couldn't, or they had to pay out of pocket because their Medicaid was no longer active.

OLGIN: All the research she did found that 4 in 10 Medicaid recipients had no idea they needed to reapply or update their addresses, and 13 million people lost coverage. McIntyre worries that if the rules about reporting work to keep Medicaid coverage go into effect, some people will be blindsided and lose it. Republican lawmakers have said these reporting requirements are a small price to pay for free or low-cost health care. And back in Kentucky, some Republican state lawmakers seem to agree. In fact, earlier this year, they added their own state-level work requirement. During the debate on the bill, Senator Chris McDaniel said...

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CHRIS MCDANIEL: This nation demands that those who can put forth effort do. But this nation has a heart. This commonwealth has a heart. This bill, it's not going to be perfect. Medicaid's too big for perfection.

OLGIN: Independent analyses find that despite assurances from Republicans that they're just asking people to report work, proposed changes to Medicaid mean at least 10 million people could lose coverage over the next 10 years.

For NPR News, I'm Alex Olgin.

(SOUNDBITE OF ALLAH-LAS' "HOUSTON") Transcript provided by NPR, Copyright NPR.

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