Medicaid Politics

Medicaid Politics: Federalism, Policy Durability, and Health Reform

Frank J. Thompson
Copyright Date: 2012
Pages: 288
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  • Book Info
    Medicaid Politics
    Book Description:

    Medicaid, one of the largest federal programs in the United States, gives grants to states to provide health insurance for over 60 million low-income Americans. As private health insurance benefits have relentlessly eroded, the program has played an increasingly important role. Yet Medicaid's prominence in the health care arena has come as a surprise. Many astute observers of the Medicaid debate have long claimed that "a program for the poor is a poor program" prone to erosion because it serves a stigmatized, politically weak clientele. Means-tested programs for the poor are often politically unpopular, and there is pressure from fiscally conservative lawmakers to scale back the $350-billion-per-year program even as more and more Americans have come to rely on it. For their part, health reformers had long assumed that Medicaid would fade away as the country moved toward universal health insurance. Instead, Medicaid has proved remarkably durable, expanding and becoming a major pillar of America's health insurance system. In Medicaid Politics, political scientist Frank J. Thompson examines the program's profound evolution during the presidential administrations of Bill Clinton, George W. Bush, and Barack Obama and its pivotal role in the epic health reform law of 2010. This clear and accessible book details the specific forces embedded in American federalism that contributed so much to Medicaid's growth and durability during this period. It also looks to the future outlining the political dynamics that could yield major program retrenchment.

    eISBN: 978-1-58901-935-5
    Subjects: Health Sciences, Political Science

Table of Contents

  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. List of Illustrations
    (pp. ix-x)
  4. Acknowledgments
    (pp. xi-xii)
  5. Frequently Used Abbreviations and Acronyms
    (pp. xiii-xiv)
  6. CHAPTER ONE Medicaid and the Health Care Crucible
    (pp. 1-33)

    In early 2011 the House of Representatives’ Budget Committee passed a resolution supported by its Republican members calling for “fundamental reform” of Medicaid—a federal grant program to the states. Led by the committee chairman, Paul Ryan (R-WI), the Republicans on the committee bemoaned that “skewed political incentives” had triggered Medicaid’s unsustainable growth. To “transform and strengthen the Medicaid safety net,” they called for devolving more authority to the states to unshackle them from “a misguided,” federally imposed, “one-size-fits-all approach.” They also proposed to slash the program’s costs by converting it to a block grant that would place new constraints...

  7. CHAPTER TWO Dodging the Block Grant Bullet and Other Signs of Resilience
    (pp. 34-69)

    This chapter follows three significant developments for Medicaid’s durability in the 1993–2010 period. All three testify to the program’s political resilience. The first is the premise that one can learn much about the sources of a program’s strength by assessing failed legislative efforts at retrenchment. In this regard I focus on the abortive attempts to convert Medicaid from an entitlement to a block grant in 1995 and 2003. Both initiatives—one led by the House of Representatives’ majority leader, Newt Gingrich, in concert with Republican governors; and the other led by the George W. Bush administration, working with Governor...

  8. CHAPTER THREE Beyond Welfare Medicine: The Take-Up Challenge
    (pp. 70-100)

    In the decades leading up to 1993, many portrayed Medicaid as “welfare medicine.” This phrase had several connotations. In a general sense, it implied that Medicaid was second-class care that gave less access to high-quality services than others received through their insurance. But in the case of children and non-disabled adults below sixty-five years of age, it also implied that Medicaid served people on welfare. Those receiving cash assistance under Aid to Families with Dependent Children (AFDC), a federal grant program to the states, automatically became eligible for Medicaid. This link to AFDC did much to brand and stigmatize Medicaid...

  9. CHAPTER FOUR Government by Waiver: The Quest to Transform Long-Term Care
    (pp. 101-133)

    In late April 2005 a House of Representatives subcommittee on health opened a hearing on the need to reform long-term care under Medicaid to contain its “spiraling costs.”¹ In his opening remarks at the session, Representative Charles Norwood (R-GA) observed that “Medicaid . . . is quickly becoming a welfare program for middle-income families. With clever estate planning and asset protection schemes, individuals can qualify for Medicaid and receive long-term care at taxpayer’s expense” (US House Committee on Energy and Commerce 2005, 5). Norwood’s statement recognizes a point made in the first chapter: that long-term care has done much to...

  10. CHAPTER FIVE Demonstration Waivers and the Politics of Reinvention
    (pp. 134-166)

    Within a month after taking office in January 1993, President Bill Clinton appeared at the winter meeting of the National Governors Association, a group with which he had been affiliated for twelve years as governor of Arkansas.¹ The president spoke words the governors wanted to hear. Clinton deemed the process that the federal bureaucracy employed to evaluate Medicaid demonstration proposals as “byzantine and counterproductive.” He asserted that “for years and years, governors had been screaming for relief from a cumbersome process by which the federal government had micromanaged the health care system affecting poor Americans.” He vowed to bring relief...

  11. CHAPTER SIX Reform: The Politics of Polarization
    (pp. 167-202)

    On March 23, 2010, President Barack Obama signed the Patient Protection and Affordable Care Act—an epic breakthrough to expand health insurance in the United States. This new law, commonly called the Affordable Care Act, or ACA, culminated a century of effort to insure all Americans. Theodore Roosevelt championed universal coverage when he ran for president on the Bull Moose ticket in 1912. The idea received serious consideration during the New Deal under Franklin Roosevelt, and President Harry Truman proposed a comprehensive plan after World War II. Sweeping proposals also surfaced during the presidencies of Richard Nixon, Jimmy Carter, and...

  12. CHAPTER SEVEN Durability, Federalism, and the Future of Medicaid
    (pp. 203-236)

    From the dawn of the Clinton administration in January 1993 to the contentious politics of divided government under Barack Obama in 2011, dramatic political and economic changes buffeted Medicaid. At various intervals the two major parties won and lost control of Congress and the presidency. The march toward asymmetric partisan polarization continued apace, with the Republican Party trending toward greater conservatism. The quest to end Medicaid as an entitlement via a block grant surged, ebbed, and surged again. Democratic policymakers scored an epic breakthrough in forging comprehensive health reform, with Medicaid as the platform, while energized Republicans vowed to achieve...

  13. Appendix A Medicaid Expenditures
    (pp. 237-238)
  14. Appendix B Medicaid Enrollees
    (pp. 239-239)
  15. Appendix C Medicaid Provisions of Key Debt-Reduction Plans
    (pp. 240-240)
  16. References
    (pp. 241-262)
  17. Index
    (pp. 263-273)