The Politics of Medicaid.The Politics of Medicaid. By Laura Katz Olson. New York: Columbia University Press. 2010. 426 pp. $32.50.
In her comprehensive overview of the history of Medicaid, Laura Katz Olson takes on the formidable job of cataloging and analyzing the social, economic, and political dynamics that have shaped the shared federal-state Medicaid program. Using the term "welfare medicine" interchangeably with Medicaid, Olson deftly walks readers through the rough terrain of the Medicaid landscape over time, pointing out again and again the inadequacies of the under-funded and highly politicized system of care that, at best, provides a Band-Aid approach to medical services. Looking through the prism of the "iron triangle" of health policy--access, cost, and quality--the author provides detailed examples of how the Medicaid program has fundamentally fallen short in the organization, financing, and delivery of health care for those most vulnerable in our society. Olson weaves this message throughout the book, attesting that the diminution of the Medicaid program has perpetuated a two-class medical system in which both Medicare and private insurance offer better access and higher quality medical services than Medicaid. As a result, welfare medicine has become a fragmented, discontinuous, highly variable state-based system of care that, according to the author, leaves many outside its reach while it contributes to the overall inadequacy of health care in the U.S.
The first half of the book meticulously lays out the chronological history of the Medicaid program, from its launch alongside Medicare in the mid-1960s through the beginning of the Obama administration. Even in the early days of the program, Medicaid received little support relative to the more legitimized Medicare program. Whereas Medicare was enshrined as a federal social insurance entitlement for "worthy" older Americans coming to the end of a productive working life, Medicaid was viewed as a state-based welfare program for certain categories of less fortunate societal ne'er-do-wells destined to rely on government handouts. This dichotomy between the two health programs, both in structure and in cultural perspective, according to Olson, divides Medicare and Medicaid to this day. As such, Medicaid continues to be viewed much more as a governmental financial liability rather than as a health plan worthy of protection.
The decades following Medicaid's birth brought changes to the program as cost-saving measures and a drive toward privatization limited beneficiaries' rights and benefits. Whether through President Reagan's "new federalism" initiative that gave states fewer Medicaid dollars in exchange for less federal oversight or during welfare reform under the Clinton administration (which delinked Medicaid from income support), families faced tougher requirements for inclusion in the Medicaid program. As a result, many were dropped altogether from Medicaid rolls or were progressively shifted into private managed care plans that limited enrollee access to certain providers and services. According to Olson, this incremental retrenchment of entitlement status in the Medicaid program climaxed during the early part of the 21st century under President George W. Bush, when efforts to dismantle welfare medicine took the form of euphemistically entitled "personal responsibility" initiatives that promised "greater choices." Instead they delivered leaner benefit packages, reduced services, and fewer consumer protections.
The second half of the book analyzes the quality of care under the Medicaid program and asks whether the U.S. system of welfare medicine is "better than nothing." The answer is an unqualified "yes," according to the author, but the affirmation is made with significant caveats due to the endemic problems within the Medicaid program. These include: inadequate coverage of the indigent population; the growing lack of access to physicians and dentists; the sorry state of long-term care with its growing prevalence of elder abuse; and the co-opting of scarce Medicaid dollars by entrepreneurial stakeholders who siphon revenues away from needy enrollees. Olson reminds us that states also exploit the Medicaid program. Even as they sponsor Medicaid and rely on it to bring employment opportunities and tax dollars into their treasuries, states seek myriad ways to draw down additional federal dollars to both pay for Medicaid services and to cross-subsidize other state requirements. The ultimate judgment regarding Medicaid's value is that everyone touched by it--the enrollees who utilize medical services as well as the many actors administering and providing the benefits--gain from the program, but in the end, nobody wants to pay the Medicaid bill.
The book finishes with a testament to the resiliency of the Medicaid program and its seemingly endless ability to survive political and economic threats. Because Medicaid is so intertwined with all the other pieces of the health care system, it is both protected by and dependent upon the current system, making significant change difficult. Olson yearns for a time when Medicaid will be given its rightful place in our nation's health care delivery hierarchy, or better yet, subsumed into an overarching single-payer health reform package. Olson's book went into publication before the final version of the Patient Protection and Affordable Care Act (ACA) was passed in the the spring of 2010, but it is clear from the concluding chapter that the author would not have supported the ACA's use of the flawed Medicaid program to shore up the policy scaffold to expand insurance coverage.
Overall, The Politics of Medicaid is a valuable cautionary tale about the ways in which well-intentioned public policies intersect with political, economic, ideological, and cultural realities. The book brings into sharp focus the historic marginalization of the Medicaid program and the ways its implementation over the last half century has failed the very people it was designed to serve.
Carolyn Long Engelhard, M.P.A.
Assistant Professor and Director, Health Policy Program
Department of Public Health Sciences
University of Virginia School of Medicine, Charlottesville