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• 1. Introduction: They Tax Dogs in West Virginia, Don’t They?
• 2. Federalism: The Power Plan
• 3. Constitutions: Operating Instructions
• 4. Political Attitudes and Participation: Venting and Voting
• 5. Parties and Interest Groups: Elephants, Donkeys, and Cash Cows
• 6. Legislatures: The Art of Herding Cats
• 7. Governors and Executives: There Is No Such Thing As Absolute Power
• 8. Courts: Turning Law into Politics
• 9. Bureaucracy: What Nobody Wants but Everybody Needs
• 10. Local Government: Function Follows Form
• 11. Metropolitics: The Hole Government Problem
• 12. Finances: Filling the Till and Paying the Bills
• 13. Education: Reading, Writing, and Regulation
• 14. Crime and Punishment
• 15. Health and Welfare Policy: State, Heal Thyself!
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Chapter 15: Health and Welfare Policy

Study

Chapter Summary
Historically, states and localities were the primary providers of healthcare and safety net programs for citizens. Following the Great Depression, however, the federal government assumed greater responsibility through the creation of Social Security, Medicaid, and Medicare. But the emergence of greater federal involvement did not permanently remove policymaking power from the states.

The devolution revolution of the 1980s precipitated a major shift in social policy. No longer was the federal government the primary actor in determining and distributing benefits. States and localities once again became the primary authorities in regard to the provision of health and welfare benefits. While the states welcomed the increase in policy flexibility, the rising costs of healthcare and welfare put undo constraints on state budgets. As a result, states and localities were forced to become more creative in social policy design and implementation. Although Medicaid continues to place an enormous fiscal burden on states, programs such as SCHIP and TANF have proven successful in terms of appropriately expanding benefits while also reducing caseloads. States continue to serve as the primary distributors of social service benefits, but decreasing federal support, faltering state economies, and the increasing need to provide long-term care to healthcare recipients are placing overwhelming burdens on states to maintain and expand existing programs.

Objectives
After reading this chapter, you should understand…

• the history of public healthcare in the United States
• welfare reform and variation in state policy responsibility
• how TANF, Medicaid, and Medicare differ
• the phrase “devolution revolution” and what it means for state policymaking
• the role of SCHIP in expanding healthcare benefits
• how the “baby boom” retirement and prescription drug costs affect state health policy

Study Questions

1. What is public health, and how has it changed over the last fifty years?


2. What is TANF, and how has it affected the role of states and localities with regard to welfare policy responsibility? Why do states vary in their approach to state welfare policy?

3. How do Medicaid and Medicare differ? Briefly discuss the history of each program.

4. What was the devolution revolution? How did it affect state policymaking? Discuss in terms of welfare and healthcare policy.

5. What is SCHIP, and how does it increase states' flexibility in regard to healthcare policy?

6. How has the role of states and localities in managing healthcare policy changed since 1990? What are some issues currently facing state lawmakers with regard to expanding healthcare coverage?