Attending to Medicaid

Abstract

[P]layers line up in a long line and hold hands. The player at the front of the line is the ‘head’ and the player at the end of the line is the ‘tail’.… The game begins when the head begins to run wildly in any direction, making sharp turns and quick double-backs.… The force created by the twists and turns will often send the tail of the whip flying.… It may be best for the tail to hold on with both hands to keep from flying off the end. Sometimes, however, the tail will go flying no matter how hard they hold on ... Be prepared to get dirty if you play this game!--"Crack the Whip: Party Game CentralIf the evolution of American health policy (in both its purposeful and its accidental forms) is compared to the children’s game of Crack the Whip, then there is no question that the Medicaid program is the tail of the line. When those at the head of the line (e.g., employer-based insurance, Medicare, managed care plans, and pharmaceutical companies) start to move. Medicaid receives whatever shocks and unintended consequences result, and when the line “begins to run wildly in any direction,” it receives them faster and harder than the players at the center.Shocks also come from other sources. When the economy slumps, an epidemic arises, or a path in another part of the system becomes a cul-de-sac, new twists and turns occur, with Medicaid absorbing much of the change.