Medicaid's Political Development since 1965: How a Fragmented and Unequal Program Has Expanded

The Medicaid program has changed enormously over the past 60 years from a very restrictive program primarily attached to recipients on public assistance in 1965 to a much more expansive program today allowing coverage for persons regardless of marital, parental, or employment status. Incorporating the "medically needy"-an ambiguous concept from the start-allowed states to include many different groups in Medicaid who are not traditionally thought of as poor. In addition, three structural features illuminate why the program has expanded and changed dramatically over time: federalism and intergovernmental financing, the dominance of the private sector, and fragmentation. Unequal treatment among Medicaid-covered groups alongside partisan politics create a political discourse that often reveals Medicaid as a public subsidy for stigmatized groups while hiding Medicaid's reach into the middle class. This central political ideological tension collides with programmatic realities such that Medicaid strangely often suffers from a residual retrenchment politics while at the same time benefiting from embeddedness, making it extremely difficult to truly turn back the clock on Medicaid's expansion.