Health Care Policy and Social Welfare Policy

There are two other broad public policy areas that affect the states.  These are health care policy and social welfare policy.

Health Care Policy

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Early public efforts at stopping diseases (in the 1800s – early 1900s) included governmental development of sewers, clean water supplies, and vaccines. Otherwise efforts were minimal and at the local government level.

The United States health care system now includes private payment for health care services, private insurance, and some government provided health insurance. Medicare is a health care program for people 65 and older and people no longer able to work because of disability. Medicaid is a program for low-income individuals and families. Both programs were introduced in 1965, and a major expansion of Medicare to include a prescription drug benefit was implemented in 2006. Medicaid involves the states in administration and financing.

The Children’s Health Insurance Program (CHIP), also known as the State Children’s Health Insurance Program (SCHIP) provides health care for children; it was signed into law in 1997. In 2009, President Obama signed the Reauthorization Act to continue the CHIP program. CHIP was extended again in 2015. CHIP also involves states in administration and financing.
Health care policy issues are quality, access, and cost. It is possible to address one or two of these with a policy, but it is difficult to achieve all three. Other developed countries provide universal coverage to insure access. Costs may be lower than in the United States.  However, quality in these other countries sometimes suffers in that not all technology is available and waits to receive coverage are sometimes longer than in the United States.  In the United States, coverage (access) is rationed through ability to pay privately, as not all have health insurance coverage.

Health care costs are high because new expensive technology is used, because payment is often through private insurance, because lack of access for the uninsured leads to emergency room visits, and because drug prices are unregulated. In all these ways, the United States differs from other countries.

Some states have adopted innovative health care programs. For example, in 2006, Massachusetts instituted a program that attempt to provide insurance for nearly everyone in the state. The program requires everyone to purchase health insurance, provides subsidies for poor and low-income persons, and expands Medicaid eligibility.

The Massachusetts state law greatly influenced the structure of the federal law, the Patient Protection and Affordable Care Act of 2010.  This federal law, also known as the Affordable Care Act, ACA, and Obamacare, mandated that Americans purchase health insurance, provided subsidies for low-income people for health care costs, and included an expansion of Medicaid.

The Affordable Care Act went into effect in 2014. It has increased coverage substantially. It has reduced the number of people without health insurance (uninsured) from about 48 million to about 27 million – from 15.7% to 8.6% of the population. Even more would be covered by Medicaid had the Supreme Court not ruled that states could not be compelled to expand Medicaid; 31 states (and DC) did expand Medicaid, 19 states did not. But Obamacare has been costly and controversial.

Texas remains the state with the highest level of uninsured residents. In 2010, about 25% of Texas were uninsured. As of 2015, the proportion is about 16% uninsured. Texas is one of the states that chose not to expand Medicaid.

With the election of President Donald Trump and House and Senate majorities, in 2017 Republicans tried to seeking to enact a new health care program to (repeal and) replace the Affordable Care Act. The effort passed in the House but failed in the Senate. The Act was weakened through executive orders and the repeal of the individual mandate in the Republican tax plan of 2017. With Democrats reclaiming the House majority in the 2018 midterm elections, there is no possibility that the ACA will be repealed, at least until after the next election.

Social Welfare Policy

Historically, social welfare was not considered a governmental responsibility. Any assistance to the poor was provided by local governments, private charities, and churches.

These practices largely collapsed with the Great Depression in the 1930’s. Starting in 1933, President Franklin D. Roosevelt and Congress offered New Deal programs: business regulation, government work programs, labor organization rights, Social Security, and direct social welfare aid.

In the 1960’s, under President Lyndon Johnson Aid to Families with Dependent Children (AFDC) was expanded as part of the War on Poverty. The introduction of Medicare and Medicaid also came in 1965.

In 1992, President Clinton vowed to “end welfare as we know it.” In 1996, the Personal Responsibility and Work Opportunity Act (1996) was passed.  This welfare reform law sets time limits on receiving welfare benefits, requires recipients to get a job or job training, and makes it more difficult to qualify for welfare assistance. Also, AFDC became Temporary Assistance to Needy Families (TANF).

Because of the nationwide recession that began in 2008, many states, including Texas, further reduced welfare benefits and increased restrictions on eligibility and length of time on TANF.  Although the population has grown in many states, inadequate funding by the federal government has in part led to much stricter provisions, according to The Center on Budget and Policy Priorities in 2011 (www.cbpp.org). States, which are required to administer and contribute to the Medicaid, CHIP, and TANF  programs, face great challenges in providing health care and social welfare for their residents.

Terms and Ideas

Health care policy issues of quality, access, and cost
Reasons for the high cost of health care
The development of New Deal social welfare policies
Medicare (1965)
Medicaid (1965)

Children’s Health Insurance Protection Act (CHIP) (1997)
The Patient Protection and Affordable Care Act (2010)
AFDC (Aid to Families with Dependent Children)
Personal Responsibility and Work Opportunity Act (1996)
TANF (Temporary Assistance to Needy Families) (1996)

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