The government program where party differences have widened the most, and matter the most, is Medicaid.
The conservative vision of a market-based system of limited subsidies for the purchase of private health insurance (and, to some extent, “personal responsibility” for buying health services from providers) that increasingly dominates Republican health policy thinking depends on Medicaid as a low-priority, high-population experiment station. As noted above, Medicaid is now central to the progressive vision of a universal health care system. This provides Republicans at the federal and state levels with a dual motive for sabotaging the Medicaid expansion, even if that means that federally run health care exchanges must pick up the slack.
In other words, two very different and largely incompatible points of view are colliding in the politics of Medicaid at the moment.
This reality is discussed by Thompson near the conclusion of his book, where his general optimism over the “durability” of Medicaid from 1993 to 2010 begins to fade. After discussing the adoption of an openly hostile position toward Medicaid by Republican members of Congress via their votes for the Ryan budget, Thompson expresses hope that Republican governors will resist the pressure to go along: “[I]f they sustain some sense of the pragmatic, incremental approach to the program that they have frequently exhibited in the past, they may well temper Medicaid cuts.”
He wrote those words before the Supreme Court decision gave the states the opportunity to opt out of the ACA’s exceptionally generous Medicaid expansion provisions. Since then, only seven of the thirty Republican governors have indicated that they will follow all but one Democratic governor in going along with the Medicaid expansion.
As occurred in the mid-’90s, the loss of bipartisan support for Medicaid may have at the same time made the program more attractive to Democrats. They did not campaign for protecting “M2E2” in 2012, but they did insist on protecting Medicaid from appropriations “sequestrations” in the 2011 deficit reduction deal that’s hanging fire in Washington in early 2013. In an era of asymmetrical polarization, that may be the best fate available for any element of the New Deal/Great Society legacy.
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