Policy Feedbacks and Medicaid on its 60th Anniversary

Abstract Context: Despite early skepticism about Medicaid's ability to withstand retrenchment as a program of “welfare medicine,” it has proved remarkably durable. Existing analyses explain durability with a policy feedbacks perspective – how program provisions affect the subsequent political environment and policymaking options. This article updates earlier feedback accounts to the ACA era. Methods: Examines extant findings on policy feedbacks in Medicaid at the elite and mass levels since the implementation of the Affordable Care Act of 2010. Findings: Mass feedbacks have been modest. Medicaid expansion under the ACA only slightly increased beneficiary political participation, if at all. Medicaid attitudes among beneficiaries and the larger public have become somewhat more supportive. Elite-level feedbacks are the most powerful, with the federal contribution, increased for expansion populations under the ACA, inexorably shaping state incentives. However, continued rejection of Medicaid expansion and attempts to add conditions to Medicaid eligibility in Republican-led states with large shares of Black residents demonstrate that federalism, race, and the program's welfare medicine image continue to threaten the program. Conclusion: Medicaid survives as the nation's largest health insurance program by enrollment, and is deeply woven into the health care system, but remains chronically vulnerable and variable across states despite robust aggregate enrollment and spending.