Medicaid Politics and Policy

Book excerpt: Medicaid is a story worth telling, one rooted in American history and shaped by its culture and institutions. It has dramatic interest, heroes and heroines, triumphs and tragedies. The authors make this story come alive for the reader by providing a strong connected narrative, detailed accounts of important policy changes, and extensive use of interviews with individuals close to events. They emphasize politics and policy along with history. History is important because Medicaid has developed incrementally, layer by layer, so that almost any provision or activity needs a historical gloss to understand it. The Medicaid program has been especially subject to outside political and policy influences: the state of the economy, trends in federalism, developments in health or welfare programs, and the electoral cycle. Politics helps us understand policy outcomes. But the two go together: a knowledge of policy helps understand what is at stake, and a knowledge of politics what is possible. A central theme of the book is that Medicaid is a "weak entitlement," one less established or effectively defended than Medicare or Social Security, but more secure than welfare or food stamps. Medicaid has the flexibility to adapt (or be adapted) as well as a capacity to defend incremental and opportunistic gains. At the same time, the program lacks an effective mechanism for overall reform. It has grown enormously since its inception to become the largest health insurance system in the country, a source of perennial complaint and, most recently, of continuing crisis. The dual emphasis upon politics and policy is important to make the arcane Medicaid program accessible to the reader, and to distinguish policy grounded in facts and analysis from partisan bombast and ideology. The result is an authoritative account and reference for those seeking to refresh a perspective or to look further.