Healthy Voices, Unhealthy Silence: Advocacy and Health Policy for the Poor

By Colleen M. Grogan; Michael K. Gusmano | Go to book overview

3
Medicaid's Persistent and
Conflicting Goals
EQUAL ACCESS, QUALITY CARE, AND COST CONTROL

Despite persistent hopes, the goal of providing the poor access to high-quality, mainstream medical care at reasonable costs has remained elusive for the last forty years, for reasons too large and complex to cover adequately in this chapter.1 Our main intent is to show, despite Medicaid's failings, how these goals have remained aspirations for the program over time. Interested groups, most notably Medicaid providers and advocates for the poor, often use these stated program goals to hold states, agency heads, and elected officials accountable for program promises left undelivered. Indeed, variations on these same goals were explicitly stated as important aspirations for Connecticut's Medicaid managed care program. We document the history of Medicaid's stated goals at the national level over time and then the explicitly stated goals in Connecticut's Medicaid reform to illustrate that these were not new goals that emerged in one state at a particular point in time but goals held across the nation since Medicaid's beginnings in 1965.

We begin by documenting briefly the rise of dual-track medical care in the United States, where the poor primarily receive substandard care in public clinics.2 This history is important if we are to understand the enormity of Medicaid's idealistic goals in 1965 to change that separate and unequal system of care. We then show how the federal government, and consequently the states, quickly retreated from these program ideals when Medicaid expenditures skyrocketed unexpectedly. This significant retrenchment created the reality, and the image, of Medicaid as welfare medicine.3 Next we explicate the expansionary side of Medicaid and show how it operates in tension with Medicaid's recurrent retrenchment policies.

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