Saint Louis University Journal of Health Law & Policy

Document Type



Medicaid has financed care for the poor for five decades. During that time it has balanced two important missions: providing for the particular health needs of the poor, and mainstreaming care for the poor. These roles have been consistent as all insurance payors—public and private—have shifted away from passively funding fragmented care to actively supporting patient-centered coordinated care. But the health needs of the poor go beyond medical interventions; the health status of the poor depends on the provision of social services to address social determinants of health, including housing, nutrition, and employment training services. Unlike non-poor insureds, Medicaid beneficiaries rely uniquely on third-party support for access to both medical care and social services. This need for a focus on funding for social as well as medical care distinguishes the circumstances of the poor, and argues for a Medicaid focus not on mimicking middle-class health insurance programs, but rather on the particular needs of the poor. These particular needs should be coordinated and funded through Medicaid Accountable Care Organizations and interagency cooperation through Health in All Policies orientations. While it is appropriate from Medicaid programs—including managed care programs—to ease the transition of beneficiaries between Medicaid and commercial insurance, it is more important than ever for Medicaid to have a particular focus on its core mission of serving the most vulnerable. As the Centers for Medicare and Medicaid Services agency turns to the regulation of Medicaid managed care programs, it should leave states sufficient flexibility to encourage innovative programs for the poor, and avoid overvaluing efforts to make Medicaid more like mainstream commercial insurance.