In 1965, fresh off a Democratic thrashing of the Republicans in the 1964 elections, President Lyndon B. Johnson had the means to push through his effort to “complete” the New Deal. This included legislation to provide government-funded medical care to four groups of the “deserving poor”: children, pregnant mothers, the disabled, and geezers who needed long-term care. So it went from 1965 to 2014, as the one-time “war on poverty” failed to end poverty in a growing population. By 2014, 57 million Americans were covered. Still, at that point, one in seven Americans (14.3 percent) had no health insurance. Then the Affordable Care Act (ACA) of 2010 kicked in, “allowing” states to use Medicaid to pay for the expenses of all able-bodied adults who earned less than 138 percent of the government’s poverty level. This added 17 million people (about 30 percent of the 2014 total) to the Medicaid rolls. By 2016 the share of Americans without medical insurance had fallen to one in twelve (8.6 percent). However, the cost of those covered by Medicaid ran to $574 billion a year.
As part of the “repeal and replace” ACA effort, House Republican proposed to reverse the ACA’s expansion of Medicaid by 2020. That is, they sought to return Medicaid to its original mission. This would involve dropping 14 million people—those able-bodied people added by the expanded Medicaid of the ACA. There also is talk of imposing a work requirement on able-bodied recipients of Medicaid.
Another part of the plan is tax cuts. The ACA imposed $875 billion in new taxes, mostly on high income earners. The Republicans want to roll back those tax increases.
Another part of the Republican plan would reduce the future growth in Medicaid spending by $834 billion over ten years. The federal government would provide states with fixed amounts of money, rather than just paying whatever bills come in. This proposal tries to address an important demographic and financial problem. Medicaid pays for home health aides and for nursing home care for those who have exhausted their own savings. A recent report by the World Economic Forum pointed out that the United States has the biggest gap between actual retirement savings and projected needed savings. U.S. government projections suggest that 70 percent of people will need long-term care. The vast majority of these will need a home health-care aide, while 18 percent will need nursing home care. Given the retirement savings gap, a huge financial cost will fall on the Medicaid system. The Republican plan tries to address that issue. It may not do that well, but one is surprised to see it done at all.
It is possible to see two distinct moral perspectives in the struggle over Medicaid. Medicaid is but one front in a fight that involves Medicare, Social Security, defense, education, and taxes. Broadly, they all touch on different conceptions of social reform and the best society.
Democrats would argue that the national government has a moral duty to its citizens. It must break down the barriers to individual success. Where those barriers can’t or can’t yet be destroyed, then the winners from current systems need to compensate the losers.
Republican would argue that such government action corrodes individual responsibility and creates dependency. It harms the very people it seeks to help. Government has a moral duty to create the conditions for individual success by fostering a dynamic economy.
It’s wishy-washy to say so, but both could be true.
 Julian Zelizer, The Fierce Urgency of Now: Lyndon Johnson, Congress, and the Battle for the Great Society (2015). Really good book.
 “The battle over Medicaid,” The Week, 23 June 2017, p. 11.