Saint Louis University Journal of Health Law & Policy

Document Type

Symposium Article


The soul of Medicaid is and always has been to achieve justice in health care. Medicaid at its inception was designed to ensure that the most vulnerable members of society are not excluded from access to good health that all others enjoy. Yet, as the title of this symposium aptly reflects, “The Struggle for the Soul of Medicaid” remains vulnerable to repeated and relentless political attacks. Why is this so, given that the program finances care for nearly sixty-four million Americans?

This article posits that Medicaid is vulnerable because our nation’s commitment to justice in health care remains uncertain. Historically, our commitment to justice in America has been limited by our willingness to bear the cost required to achieve justice. Moreover, our commitment has often been further limited by our inability to empathize with people who need Medicaid assistance in order to gain access to health care. We have limited the program to the “categorically” needy. Those who “deserve” help gaining access to health care. And more recently, some have used work requirements to ensure that Medicaid health benefits are meted out only to those worthy of receiving them. In contrast, the legislative purpose of the Act was so clear to its proponents, and so aligned with their shared foundational values as well as the values upon which our democracy rests, that in 1965, little more needed to be said in defense of Medicaid. That it provided a nationwide safety net for many of society’s poor and destitute to receive health care, regardless of their ability to pay, may have been justification enough for the program.

However, simply identifying justice as the ethical value that lies at the soul of the Medicaid program cannot save it. Justice takes many forms, and its many expressions can serve to justify competing and even mutually exclusive ends where Medicaid is concerned. Egalitarian conceptualizations inspire Medicaid’s communitarian commitment to provide access to health care for society’s neediest to equalize the opportunity to participate in society. Utilitarian justice may aim to maximize societal health but might not accomplish these ends by identifying some poor or needy members of society as more deserving than others. And libertarian justice ideals counsel minimizing the cost burden that Medicaid places on non-beneficiaries. Notwithstanding the epistemological struggle, the Medicaid program remains quite popular with Americans, regardless of party affiliation. Republicans learned this during their failed multiple efforts to repeal-and-replace the Affordable Care Act.

This article argues that the justice that originally motivated the Medicaid mission has survived as the program’s chief animating principle. That egalitarian vision of justice compels policymakers to stretch Medicaid’s already scarce and over-burdened resources far beyond the clinical setting to rectify inequitable distribution of the social and environmental risk factors that disproportionately threaten the health of Medicaid-eligible populations. The unfairness of this additional burden on the program is not trivial. We already ask far too much of the program. Yet, the point of this article is to clarify why and how Medicaid can do even more than it does today to fulfill the mandates of justice, and thereby contribute substantially to nation-wide health equity.