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Medicaid is a story worth telling, one rooted in American history and shaped by its culture and institutions. It has dramatic interest, heroes and heroines, triumphs and tragedies. The authors make this story come alive for the reader by providing a strong connected narrative, detailed accounts of important policy changes, and extensive use of interviews with individuals close to events. They emphasize politics and policy along with history. History is important because Medicaid has developed incrementally, layer by layer, so that almost any provision or activity needs a historical gloss to understand it. The Medicaid program has been especially subject to outside political and policy influences: the state of the economy, trends in federalism, developments in health or welfare programs, and the electoral cycle. Politics helps us understand policy outcomes. But the two go together: a knowledge of policy helps understand what is at stake, and a knowledge of politics what is possible. A central theme of the book is that Medicaid is a "weak entitlement," one less established or effectively defended than Medicare or Social Security, but more secure than welfare or food stamps. Medicaid has the flexibility to adapt (or be adapted) as well as a capacity to defend incremental and opportunistic gains. At the same time, the program lacks an effective mechanism for overall reform. It has grown enormously since its inception to become the largest health insurance system in the country, a source of perennial complaint and, most recently, of continuing crisis. The dual emphasis upon politics and policy is important to make the arcane Medicaid program accessible to the reader, and to distinguish policy grounded in facts and analysis from partisan bombast and ideology. The result is an authoritative account and reference for those seeking to refresh a perspective or to look further.
The Children’s Health Insurance Program was crafted in a period of intense partisan and ideological controversy over health care entitlements to provide "creditable coverage" for American children below 200 percent of the Federal Poverty Level. This objective was widely supported, though achieved only by a compromise between the structural alternatives of a block grant, similar to the Maternal and Child Health Block Grant or an entitlement resembling Medicaid. According to David G. Smith, the CHIP compromise has been a successful experiment that far exceeded expectations, both in identifying and enrolling "targeted low-income children" and in earning political capital. He argues that beyond this core mission, the reauthorization of CHIPRA (Children’s Health Insurance Program Reauthorization Act of 2009) invites a larger mission: going beyond enrollment of children to include assuring access, improving quality, and containing costs of health care for them. Extending this thrust, the author notes that CHIP could be used to establish children’s health as a niche—much like care for the elderly—within the larger scheme of health care insurance for all. Several areas of successful performance needed for the program to be adjudged a success as well as its limitations are discussed in the book. These areas include initial implementation, enrolling kids, federal-state relations, and the uses and misuses of waivers to modify the program. A description of changes made by the CHIPRA reauthorization and the new Patient Protection Affordable Care Act (PPACA) is also included. This is followed by a consideration of lessons learned from CHIP’s evolution and recommendations for future development. In short, this is a valuable and readable account for those interested in the current and future trends of health care for the young.
An engagingly written, meticulously documented study of antislavery ferment just north of the Mason-Dixon line in a region of geographical, economic, cultural, and historical "edges". In On the Edge of Freedom, David G. Smith breaks new ground by illuminating the unique development of antislavery sentiment in south central Pennsylvania-a border region of a border state with a complicated history of slavery, antislavery activism, and unequal freedom. During the antebellum decades every single fugitive slave escaping by land east of the Appalachian Mountains had to pass through the region, where they faced both significant opportunities and substantial risks. While the hundreds of fugitives traveling through south central Pennsylvania (defined as Adams, Franklin, and Cumberland counties) during this period were aided by an effective Underground Railroad, they also faced slave catchers and informers. "Underground" work such as helping fugitive slaves appealed to border antislavery activists who shied away from agitating for immediate abolition in a region with social, economic, and kinship ties to the South. And, as early antislavery protests met fierce resistance, area activists adopted a less confrontational approach, employing the more traditional political tools of the petition and legal action. Smith traces the victories of antislavery activists in south central Pennsylvania, including the achievement of a strong personal liberty law and the aggressive prosecution of kidnappers who seized innocent African Americans as fugitives. He also documents how their success provoked Southern retaliation and the passage of a strengthened Fugitive Slave Law in 1850. The Civil War then intensified the debate over fugitive slaves, as hundreds of escaping slaves, called "contrabands" sought safety in the area, and scores were recaptured by the Confederate army during the Gettysburg campaign. On the Edge of Freedom explores in captivating detail the fugitive slave issue through fifty years of sectional conflict, war, and reconstruction in south central Pennsylvania and provocatively questions what was gained by the activists' pragmatic approach of emphasizing fugitive slaves over immediate abolition and full equality. Smith argues that after the war, social and demographic changes in southern Pennsylvania worked against African Americans achieving equal opportunity, and although local literature portrayed this area as a vanguard of the Underground Railroad, African Americans still lived "on the edge of freedom." By the 1920s, the Ku Klux Klan was rallying near the Gettysburg battlefield, and south central Pennsylvania became, in some ways, as segregated as the Jim Crow South. The fugitive slave issue, by reinforcing images of dependency, may have actually worked against the achievement of lasting social change.
Entitlement Politics describes partisan attempts to shrink the size of government by targeting two major federal health care entitlements. Efforts to restructure or eliminate entitlements as such, and to privatize and decentralize programs, along with more traditional attempts to amend and reform Medicare and Medicaid have radically transformed policymaking with respect to these programs. However, they have failed to achieve fundamental or lasting reform. Smith combines historical narrative and case studies with descriptions of the technical aspects and dynamics of policymaking to help the consumer understand how the process has changed, evaluate particular policies and outcomes, and anticipate future possibilities. His account intentionally goes at some length into the substance of the programs, the policies that are involved, and the views of different protagonists about the major issues in the dispute. One unhealthy consequence of politicizing Medicare and Medicaid policy has been to separate public debate from the technical and organizational realities underlying issues of cost containment or program structure. Smith considers this development unfortunate, since it leaves even informed citizens unable to evaluate the claims being made. Ironically, strife over Medicare has complicated the political and policy issues in American life. Only a serious and genuine bipartisan effort bringing forth the best efforts of both political parties--and some of the best industry leaders and policy experts in the field--is likely to achieve genuine reform. The more people and parties know about the history, politics, and policies of these programs, the better our prospects for devising workable, equitable, and lasting solutions. This volume leads the way toward that understanding. David G. Smith is Richter Professor Emeritus of Political Science at Swarthmore College and has been a student of health policy since 1965. Among his books is an earlier study of health policy, Paying for Medicare.
In On the Edge of Freedom, David G. Smith breaks new ground by illuminating the unique development of antislavery sentiment in south central Pennsylvania a border region of a border state with a complicated history of slavery, antislavery activism, and unequal freedom. During the antebellum decades every single fugitive slave escaping by land east of the Appalachian Mountains had to pass through the region, where they faced both significant opportunities and substantial risks. While the hundreds of fugitives traveling through south central Pennsylvania (defined as Adams, Franklin, and Cumberland counties) during this period were aided by an effective Underground Railroad, they also faced slave catchers and informers. "Underground" work such as helping fugitive slaves appealed to border antislavery activists who shied away from agitating for immediate abolition in a region with social, economic, and kinship ties to the South. And, as early antislavery protests met fierce resistance, area activists adopted a less confrontational approach, employing the more traditional political tools of the petition and legal action. Smith traces the victories of antislavery activists in south central Pennsylvania, including the achievement of a strong personal liberty law and the aggressive prosecution of kidnappers who seized innocent African Americans as fugitives. He also documents how their success provoked Southern retaliation and the passage of a strengthened Fugitive Slave Law in 1850. The Civil War then intensified the debate over fugitive slaves, as hundreds of escaping slaves, called "contrabands" sought safety in the area, and scores were recaptured by the Confederate army during the Gettysburg campaign. On the Edge of Freedom explores in captivating detail the fugitive slave issue through fifty years of sectional conflict, war, and reconstruction in south central Pennsylvania and provocatively questions what was gained by the activists' pragmatic approach of emphasizing fugitive slaves over immediate abolition and full equality. Smith argues that after the war, social and demographic changes in southern Pennsylvania worked against African Americans achieving equal opportunity, and although local literature portrayed this area as a vanguard of the Underground Railroad, African Americans still lived "on the edge of freedom." By the 1920s, the Ku Klux Klan was rallying near the Gettysburg battlefield, and south central Pennsylvania became, in some ways, as segregated as the Jim Crow South. The fugitive slave issue, by reinforcing images of dependency, may have actually worked against the achievement of lasting social change.
The Children's Health Insurance Program was crafted in a period of intense partisan and ideological controversy over health care entitlements to provide -creditable coverage- for American children below 200 percent of the Federal Poverty Level. This objective was widely supported, though achieved only by a compromise between the structural alternatives of a block grant, similar to the Maternal and Child Health Block Grant or an entitlement resembling Medicaid. According to David G. Smith, the CHIP compromise has been a successful experiment that far exceeded expectations, both in identifying and enrolling -targeted low-income children- and in earning political capital. He argues that beyond this core mission, the reauthorization of CHIPRA (Children's Health Insurance Program Reauthorization Act of 2009) invites a larger mission: going beyond enrollment of children to include assuring access, improving quality, and containing costs of health care for them. Extending this thrust, the author notes that CHIP could be used to establish children's health as a niche--much like care for the elderly--within the larger scheme of health care insurance for all. Several areas of successful performance needed for the program to be adjudged a success as well as its limitations are discussed in the book. These areas include initial implementation, enrolling kids, federal-state relations, and the uses and misuses of waivers to modify the program. A description of changes made by the CHIPRA reauthorization and the new Patient Protection Affordable Care Act (PPACA) is also included. This is followed by a consideration of lessons learned from CHIP's evolution and recommendations for future development. In short, this is a valuable and readable account for those interested in the current and future trends of health care for the young.
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