Medicaid's Remarkable Resilience

• Author: Shanna Rose
• DOI: http://doi.org/10.1111/puar.12197
• Date: 01 May 2014
• Published date: 01 May 2014

Book Reviews 423

Shanna Rose is clinical assistant

professor in the Robert F. Wagner Graduate

School of Public Service at New York

University. She is author of Financing

Medicaid: Federalism and the Growth

of America’s Health Care Safety Net

(University of Michigan Press, 2013).

E-mail: shanna.rose@nyu.edu

Book Reviews

Public Administration Review,

Vol. 74, Iss. 3, pp. 423–424. © 2014 by

The American Society for Public Administration.

DOI: 10.1111/puar.12197.

and conservative opposition. Moreover, several of

Medicaid’s programmatic features—such as means

testing and voluntary state administration—would

seem to heighten its vulnerability, potentially subject-

ing the program to interstate economic competition

and a “race to the bottom” in coverage.

Nonetheless,  ompson notes, a set of countervail-

ing forces have promoted Medicaid’s resilience and

growth. First, the “veto points” embedded in the

fragmented American political system (e.g., separa-

tion of powers, divided government, and federalism)

pose obstacles to retrenchment. Second, Medicaid

is increasingly a program for not only the poor but

also the (relatively politically powerful) middle class,

particularly when it comes to long-term care for the

elderly and disabled.  ird, in addition to its direct

benef‌i ciaries, Medicaid also enjoys the support of

another constituency: the health care providers that

receive reimbursement from the program. Finally,

f‌i scal federalism has promoted Medicaid’s durability

and growth, as shared federal–state f‌i nancing lowers

each level of government’s cost of adopting expansive

policies.

 ompson uses case studies to demonstrate how these

forces have served to protect and expand Medicaid,

focusing his analysis on the 1990s and 2000s. For

instance, he traces congressional Republicans’ failure

to convert the program to a block grant in the

mid-1990s to opposition among Medicaid’s increas-

ingly middle-class elderly benef‌i ciaries, which, in

turn, served to bolster the Clinton administration’s

r esistance—and repeated vetoes. In another case

study,  ompson argues that although the states’ use

of research and demonstration waivers has weakened

Medicaid as an entitlement—through the adoption of

enrollment caps, cost sharing, and the like—waivers

have had a net expansionary ef‌f ect on the program by

enabling states to secure federal funds to cover addi-

tional people and services that would ordinarily not

be permissible under federal law. A third case study

examines how Massachusetts state leaders leveraged

Frank J.  ompson, Medicaid Politics: Federalism,

Policy Durability, and Health Reform (Washington,

DC: Georgetown University Press, 2012). 288 pp.

$34.95 (paper), ISBN: 9781589019348; $34.95

(eBook), ISBN: 9781589019355.

In 1965, Congress created two new programs:

Medicare for the elderly and Medicaid for the

poor. At the time, proponents of national health

insurance hoped—and opponents feared—that the

universal Medicare program might eventually pave the

way for a single-payer health care system. By contrast,

policy makers, interest groups, and the news media

all assumed that the means-tested, state-administered

Medicaid program would—as programs for the poor

often do—remain small, inconsequential, and vulner-

able to retrenchment.

Half a century later, Medicaid covers one in f‌i ve

Americans, or 62 million people, compared to the

50 million covered by Medicare. And after numerous

failed attempts at national health care reform span-

ning several decades, in 2010, Congress passed the

Patient Protection and Af‌f ordable Care Act (ACA),

which included a major expansion of Medicaid

eligibility. Although a 2012 U.S. Supreme Court deci-

sion allowed the states to opt out of the expansion, a

majority of states are now extending eligibility under

the ACA, bringing millions of additional people into

the program. Contrary to expectations, it has been

Medicaid—not Medicare—that has served as a spring-

board for comprehensive health care reform in the

United States.

How has this humble program for the poor def‌i ed

expectations by enduring and expanding over the

years?  is question is at the heart of Frank J.

 ompson’s book, Medicaid Politics: Federalism, Policy

Durability, and Health Reform.  ompson points out

that Medicaid’s persistence over the past f‌i ve decades

is particularly surprising in light of the many pressures

for retrenchment, including rising health care costs,

the aging of the population, economic downturns,

Medicaid’s Remarkable Resilience

Sonia M. Ospina and Rogan Kersh, Editors

Shanna Rose

New York University