The Remarkable Expansion of Medicaid

When Congress created Medicaid under Title XIX of the Social Security Amendments of 1965, national lawmakers envisioned it as a safety net for only the poorest and most vulnerable citizens. They predicted that state officials would be measured and circumspect about participating in the new program, as they had been with previous health care programs for the poor, thereby limiting federal outlays. Upon the program’s inception, however, state officials “rudely jostled their way toward the Title XIX trough, to the increasing consternation of legislators and administrators in Washington” (Stevens and Stevens 2003, 81). The program’s chief architect, fiscally conservative House Ways and Means Chairman Wilbur Mills (D-AR), later called Medicaid the most expensive mistake of his career (Zelizer 1998, 262). He and other lawmakers began drafting legislation to scale back the program almost immediately, but state officials successfully fought off these and subsequent efforts at retrenchment. On several occasions the governors also lobbied for federal policy changes to greatly expand eligibility for the program.