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Medicaid Politics

Federalism, Policy Durability, and Health Reform

Frank J. Thompson

Publication Year: 2012

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.

Published by: Georgetown University Press

Series: American Governance and Public Policy series

List of Illustrations

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pp. ix

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pp. xi-xii

In seeking to fathom the nature and origins of Medicaid durability from President Clinton to President Obama, I have benefited greatly from the assistance of others. I am deeply indebted to the Robert Wood Johnson Investigator Award Program for funding my research. The foundation’s generous support...

List of Abbreviations and Acronyms

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pp. xiii

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1. Medicaid and the Health Care Crucible

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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...

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2. Dodging the Block Grant Bullet and Other Signs of Resilience

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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...

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3. Beyond Welfare Medicine: The Take-Up Challenge

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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...

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4. Government by Waiver: The Quest to Transform Long-Term Care

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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.” In his opening remarks at the session, Representative Charles Norwood (R-GA) observed that “Medicaid . . . is quickly becoming a welfare...

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5. Demonstration Waivers and the Politics of Reinvention

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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. The president spoke words the governors wanted to hear. Clinton deemed the...

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6. Reform: The Politics of Polarization

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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...

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7. Durability, Federalism, and the Future of Medicaid

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pp. 203-235

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...


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pp. 237-240


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pp. 241-262


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pp. 263-273

E-ISBN-13: 9781589019355
E-ISBN-10: 1589019350
Print-ISBN-13: 9781589019348
Print-ISBN-10: 1589019342

Page Count: 288
Illustrations: 3 figures, 12 tables
Publication Year: 2012

Series Title: American Governance and Public Policy series