The Battle For Medicaid: Welfare or Entitelement?

By Amanda Grigg

The term entitlement wasn’t used regularly in American politics until the 1980s, when Ronald Reagan began using it frequently – likely to avoid uttering that-which-must-not-be-named (Social Security). Today the term is almost inescapable, especially during debates over the deficit (and probably for the same reasons that Reagan used it). By complaining about “entitlements” politicians can talk about popular plans like cutting spending and lowering the deficit without explicitly mentioning cutting popular programs like Social Security.

People talk about entitlements when they talk about the deficit because entitlement programs make up the majority of the federal budget (about 60% in proposed 2013 budgets), because entitlement programs tend to be large and have steady growth, and because they have a privileged place in the budgetary process. Sometimes when people say entitlements they mostly mean this: relatively large federal benefit programs whose spending is mandatory and not subject to traditional budget cuts.

But entitlements are defined by much more than their size and budgetary restrictions. The term also tends to refer to the most beloved anti-poverty programs in the country, and some of the only social support programs whose benefits are both widely recognized and respected.

art.medicareNotably, entitlement programs are also characterized by  a sense of the public’s right to access them (a fundamental difference between entitlements and programs people refer to as “welfare”). That’s why people can say “don’t cut MY Social Security/Medicare/Medicaid” without sounding crazy (keep your government hands off my Medicaid is another story). Beneficiaries feel entitled to these benefits and thus entitled to raise a major stink over any proposed cuts (something that traditional “welfare” beneficiaries haven’t done en masse since the 1970s).  This is exactly the kind of attitude Arkansas was trying to avoid when it included language explicitly denying entitlement to Medicaid in recent legislation passing the Medicaid expansion. As sponsor Senator Jonathan Dismang explained, “The point of this language is to ensure that the individual does not think he has a perpetual right to the program.”

In his Democratic National Convention speech in 2012 former president Bill Clinton aimed to do the opposite, framing Medicaid as an entitlement by emphasizing  the high proportions of Medicaid spending on groups associated with entitlements (the elderly and the middle class). He highlighted Medicaid spending on nursing home care for the elderly and reminded the audience that, “A lot of that money is also spent to help people with disabilities, a lot of middle-class families whose kids have Down syndrome or autism or other severe conditions.” Similarly one of Medicaid’s champions in Congress, Rep. Harry Waxman has said that as a result of expansion ““we’ll see a whole lot of grateful Americans, and a whole lot more support for Medicaid, in areas where it has traditionally been scorned as a poor people’s program.””

There is a clear battle brewing between those attempting to reframe Medicaid as a middle class entitlement akin to Social Security, and those like Arkansas Senator Dismang and Paul Ryan (among many others) who are fighting to keep Medicaid in the category of welfare (or welfare-ish) spending. Why is this worth fighting over? Well…

Welfare scholars have long argued that in the US, the social groups a program is associated with and whether or not a program is thought of as an entitlement (which are closely related) have enormous consequences on its structure and public image. The US is generally agreed to have a stratified or dual track welfare system with a superior track (entitlements) and an inferior track (need-based benefits often called “welfare’) characterized by deserving/undeserving beneficiaries, contributory/noncontributory programs, and rights-based and need-based programs. The generosity of the historically white, male entitlement track has repeatedly been contrasted with the limited benefits of the female and minority-dominated need-based track in order to demonstrate the raced and gendered origins of welfare. These traditionally male-dominated entitlement track programs include Social Security and Social Security Disability Insurance (SSDI) as well as Veterans Benefits. They are often referred to as upper track programs because they offer more generous benefits and are (quite problematically, as feminists suggest) much more popular among the public. These programs are federally administered, with relatively stable nationally uniform requirements. In the case of Social Security, a mythology has developed to assert that recipients are only getting back what they paid in and are thus certainly “owed” and deserving of their benefits.  Traditionally female and minority-dominated need-based programs include Food Stamps, Medicaid, and Aid to Families with Dependent Children (AFDC). After the welfare reform efforts of the 1990s, AFDC was replaced with Temporary Aid to Needy Families or TANF, the program people generally refer to when speaking (generally derogatorily) of “welfare” – though in fact many of these lower track programs no longer fit the definition of welfare (cash assistance to the poor that doesn’t require them to enter into any institution, including the workforce, in order to receive it). These programs tend to be less generous in the amount and form of benefits offered, and much less popular among the public, which makes them more vulnerable to benefit cuts. They rarely offer cash assistance and often include demanding application processes and extensive surveillance of recipients.

tumblr_mby0uuATEu1rwkx4nPopular dislike for need-based programs and respect for entitlement programs supports the maintenance of significant structural differences between the two tracks. Individuals are much more likely to support generous benefits for groups they deem deserving. Thus discourses that misleadingly label welfare recipients undeserving, Cadillac-driving “welfare queens” (and often invoke race and class biases and stereotypes) direct public support toward less generous, more restrictive welfare programs for the poor (i.e.the ever-popular drug tests for welfare recipients). This helps to explain why entitlement programs tend to have extremely limited supervision, relatively generous benefits and unlimited benefit periods, while need-based programs considered “welfare” tend to have extensive supervision and declining benefits with lifetime limits.

In the 25 states (and counting) embracing the Medicaid expansion, beneficiaries now include groups like recent college grad, retirees who don’t yet qualify for Medicare and people between jobs, many of whom are firmly middle class. It makes sense that supporters would see an opening in these changes in Medicaid’s beneficiary demographics since demographics have traditionally been closely tied to which track of welfare a program is on. And it’s no surprise that supporters of Medicaid are trying to squeeze it into that sweet sweet entitlement bubble, or that critics are so opposed to this that they’re legislating the meaning of Medicaid – it (really) pays to be on the right side of the tracks.

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