Will ACA Make Medicaid a Middle Class Entitlement?

I’ve spent a fair amount of time fretting over the impact of the Affordable Care Act on Medicaid, particularly if Republican-controlled states succeed in convincing the Obama administration to do whatever they want to the program in exchange for a basic expansion of eligibility into previously non-qualified elements of the population (especially working poor folks without dependent children). Having spent a good part of my adult life defending Medicaid (often by scolding other liberals for their relative indifference to the program thanks to a politically driven obsession with Medicare), my knee does begin to jerk a bit when doors are opened wide to its “reform” by people who don’t much believe in it to begin with.

But at TNR Noam Scheiber articulates one reason to think otherwise:

Under Obamacare, uninsured people who earn up to 138 percent of the poverty level (just under $16,000 for a single person in 2013), can qualify for Medicaid, at least in states that opt into the law.3 This has a few key political consequences, as [Harold] Pollack notes. First, it transforms the political constituency for the program. Historically, Medicaid has served extremely poor, frequently minority, patients who either don’t vote or support Democrats when they do. That meant the GOP had no hang-ups about squeezing it. But there will likely be millions of white working-class voters on Medicaid in the coming years. (Even in some conservative states, like Arkansas, Kentucky, and West Virginia.) Once that happens, something tells me Republicans will become more charitably-disposed to the program.

This cheerful prophecy assumes, of course, that HHS waivers enabling Medicaid expansion don’t undermine this upscale direction to a great degree.

Now there’s always been one middle-class constituency for Medicaid: those utilizing it for long-term care for themselves or (more often) their parents. That’s not, interestingly enough, a big part of Medicaid’s public profile, even though it consumes nearly a third of Medicaid spending. The “expanded” Medicaid services for basic preventive and acute care presumably won’t differ from what the poorest families have long received. So maybe it will make Medicaid more of a “middle-class entitlement.” More immediately, it may create a constituency better able to demand genuine “Medicaid” reform–you know, “reform” that doesn’t amount to letting the feds and then the states shift costs to beneficiaries.

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Ed Kilgore

Ed Kilgore, a Monthly contributing editor, is a columnist for the Daily Intelligencer, New York magazine’s politics blog, and the managing editor for the Democratic Strategist.