Poor Program’s Progress: The Unanticipated Politics Of Medicaid Policy

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Abstract
PROLOGUE: The U.S. Census Bureau recently reported that the number of unin- sured people topped 41.2 million in 2001—up from 39.8 million in 2000. Interest- ingly, Medicaid, in some ways defying its statutory history, has, together with SCHIP, emerged as a primary vehicle for the incremental extension of health care benefits to the roughly 15 percent of the population still lacking basic coverage. Within the past year the U.S. Department of Health and Human Services has built upon this tradition by allowing states even greater latitude in reconfiguring Medicaid to expand coverage eligibility among the uninsured and provide pre- scription drugs to low-income seniors. In this paper Lawrence Brown and Michael Sparer trace the divergent political evolutions of the Medicaid and Medicare programs and draw lessons validating the somewhat counterintuitive notion that Medicaid, a "poor people's program," may ultimately hold the key to reducing the number of insured people. For exam- ple, despite Medicare's universal coverage standards, dedicated financing stream, and "tidy" central administration, its benefits and beneficiary categories have changed little over time. In contrast, the means-tested, general revenue-financed, and decidedly "untidy" federal-state-administered Medicaid program has main- tained its relatively extensive benefits in the face of economic uncertainty and greatly expanded its eligibility criteria. Moreover, although Medicare's federal governance has administered universal coverage, it has forgone the flexibility states and localities enjoy with Medicaid in formulating creative structural solu- tions and implementing "reforms" such as managed care. Both authors are well suited to lend insight into these complex issues. Brown is a professor in the Department of Health Policy and Management at the Joseph L. Mailman School of Public Health of Columbia University and a former Brookings Institution senior fellow. A political scientist, he holds a doctorate in government from Harvard. Sparer is an associate professor in that department. He holds a law degree from Rutgers and a doctorate in political science from Brandeis.

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