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Running in Place

How the Medicaid Model Falls Short, and What to Do about It

By Eliot Fishman

Perhaps the most glaring failure of the American mixed public/private health care system is that millions, including many of the most vulnerable, go without health insurance. In Running in Place, Eliot Fishman analyzes the various means-tested health insurance initiatives instituted at the state level since the 1960s and finds that, while there have been successes, on the whole these programs have never come close to fulfilling expectations regarding increasing the numbers of low-income people enrolled or their access to mainstream health providers. Fishman argues that such state-administered measures, modeled on Medicaid, the oldest and largest of the programs, will not bring the nation close to the goal of universal coverage. At the same time, sweeping reforms that have been proposed, such as a federally administered single-payer plan, are not feasible given the current political atmosphere in Washington. Steering between these two poles—retaining the decentralizing features of the Medicaid model that make it popular while increasing its effectiveness—will require that the federal government assume more of the fiscal burden even as states continue to run their own programs. More people will be covered if enrollment becomes automatic, with eligibility verified retrospectively, and the appeal of such programs will increase if they are broadened to include working families who are having trouble finding affordable insurance.

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