Examining the Evolution of the Medicaid Program Under Clinton, Bush, and Obama

Medicaid: Political durability, democratic process, and health care reform

    • February 20, 2014

Frank J. Thompson, PhD, examined Medicaid’s evolution primarily during the Clinton, G.W. Bush, and Obama presidential terms, as well as the forces shaping the durability of the Medicaid program, its pivotal role in health reform, and the implications for the future.

Dates of Project: July 2008 to July 2013

A distinguished professor in the School of Public Affairs and Administration at Rutgers University-Newark and the Rutgers Center for State Health Policy, Thompson wrote a book, Medicaid Politics: Federalism, Policy Durability, and Health Reform and five articles on related topics.

His research primarily relied on a qualitative, case study methodology that drew on scholarly and professional literature, archival materials, state and federal data, major newspapers and specialized health media, and interviews with over 50 Medicaid stakeholders at the state level (e.g., Medicaid officials and presidents of the hospital association).

Key Findings

  • Despite (and even because of) Medicaid’s erosion as a service entitlement program, expenditures and enrollment relative to need grew appreciably from 1992 to 2009.

  • While continuing to face significant problems of provider network adequacy, Medicaid became a stronger program in several respects during the period from 1993 to the Affordable Care Act in 2010.

  • Findings concerning Medicaid durability provide support for the “catalytic model of federalism” in which a synergy between federal and state governments fuels the growth of social programs.

  • There is wide variation in state Medicaid expenditures and in the number of enrollees per 100 persons living below the poverty line. With some large states declining to adopt the Medicaid expansion that the Affordable Care Act was originally designed to encourage, greater variation is likely in the future.

Medicaid waivers foster greater flexibility and capacity for decision-making, especially under conditions of partisan polarization and legislative gridlock.

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Medicaid Politics by Frank Thompson examines Medicaid's evolution during Clinton, GW Bush & Obama terms.