The Indispensable Health Care Program

Since I’ve been writing about health care policy this morning, thought I should mention a book review I wrote that appears in the current issue of the Monthly.

The book in question is a wonky but very useful tome on the history and trajectory of the country’s major program providing health care for low-income Americans, those with disabilities, and the elderly needing long term-care: Medicaid Politics: Federalism, Policy Durability, and Health Reform, by Rutgers professor Frank J. Thompson. Thompson mainly focuses on the complex evolution of Medicaid from the beginning of the Clinton administration to the enactment of the Affordable Care Act. But it’s immensely illuminating in examining how this essential program, which began life as a concession to Republicans and long enjoyed strong bipartisan support, became a political football in the fight between the parties at the federal and state levels.

Aside from its involvement in the coverage scheme for Obamacare, Medicaid has lately become a prime and continuing target for conservative budget-cutters in Washington, as I noted in the review:

The major threats to the entitlement status of Medicaid have been a series of three Republican efforts to turn it into a “block grant” with capped funding and extensive state control over eligibility and services. The first effort was probably the most serious, made by a Republican Congress in 1995 in the budget showdown with Bill Clinton that produced two government shutdowns before Congress retreated. Thompson analyzes this and subsequent “block grant” battles in great detail, noting that in each case the typical unity of governors over Medicaid policy succumbed to national partisan pressures. The ’95 fight had another political by-product Thompson does not mention: the elevation of Medicaid into a big Democratic Party priority, as evidenced by the 1996 Clinton-Gore ticket’s mantra of balancing the budget while protecting what became known as “M2E2”: Medicare, Medicaid, Education, and the Environment.

The third Medicaid block grant fight is theoretically still under way: it was a feature of the “Ryan budget” passed twice by House Republicans in 2011 and 2012. Indeed, the relative treatment of Medicaid and Medicare in the Ryan budget showed that perceptions of the two programs’ political saliency remained: even as analysts showed that the Medicaid block grant would reduce real funding for the program by about a third over ten years, the budget’s treatment of Medicare (with the biggest cuts back-loaded to the distant future and eliminated entirely for current and soon-to-be beneficiaries) got vastly more attention.

Regular readers know I spent a lot of time during the 2012 campaign fretting over the relatively low emphasis placed on Medicaid by progressives in the budget and health care battles. Now the fight over Obamacare implementation has raised Medicaid’s profile significantly. It would be nice if it never again slipped off the radar screen.

Washington Monthly - Donate today and your gift will be doubled!

Support Nonprofit Journalism

If you enjoyed this article, consider making a donation to help us produce more like it. The Washington Monthly was founded in 1969 to tell the stories of how government really works—and how to make it work better. Fifty years later, the need for incisive analysis and new, progressive policy ideas is clearer than ever. As a nonprofit, we rely on support from readers like you.

Yes, I’ll make a donation

Ed Kilgore

Ed Kilgore is a political columnist for New York and managing editor at the Democratic Strategist website. He was a contributing writer at the Washington Monthly from January 2012 until November 2015, and was the principal contributor to the Political Animal blog.