Medicaid at 50: No Longer Limited to the "Deserving" Poor?

Abstract

For the first fifty years of its existence, Medicaid suffered from a serious defect. While it was adopted to meet the health care needs of the poor, it only met the needs of the so-called “deserving” poor — children, pregnant women, single caretakers of children, and disabled persons — people who could not fairly be held accountable for their inability to afford health care insurance.

The Affordable Care Act (ACA) seemingly has abandoned Medicaid’s conception of the deserving poor with its expansion of the Medicaid program to all persons up to 138% of the federal poverty level. One no longer needs to be a child, disabled, pregnant, or a caretaker of a child to be eligible for Medicaid; it is sufficient simply to be poor.

In this essay, I consider the significance of this major modification of the Medicaid program. Does the ACA signal a more generous view of the deserving poor, or even an abandonment of the distinction between the poor and the “deserving” poor? Or does the ACA tell us more about the nature of health care than about societal views of the poor? And what do the answers to these questions tell us about the durability of the Medicaid expansion? Can we expect Congress to maintain the ACA’s revision of Medicaid for the next fifty years?

Most likely, the Medicaid expansion reflects concerns about the high costs of health care rather than an evolution in societal thinking about the “deserving” poor. As a result, the expansion may not provide a durable source of health care coverage for the expansion population.