Personal Responsibility: A Plausible Social Goal, but Not for Medicaid Reform

Since 2001, the Bush administration has encouraged states to incorporate "personal responsibility" measures in their Medicaid plans. These measures can take a number of forms. For example, since the early 1970s--long before the current reform efforts--some states have obtained waivers to impose higher out-of-pocket costs on beneficiaries. Other, newer proposals include health spending accounts that reward beneficiaries for demonstrating "healthy behaviors"; mandates that beneficiaries select their own health plan from several offered or lose coverage; and the use of "personal responsibility" pledges to which beneficiaries must adhere in order to receive "enhanced" benefits. The administration is promoting the measures through what are known as Section 1115 waivers--state-specific releases from federal program requirements to allow experimentation with the content or administration of Medicaid programs. More recently, the administration has also done so through state plan amendments newly permitted by the federal Deficit Reduction Act of 2005. Granting the features is very likely within the legal purview of the federal government, and seeking them appears to be legal for states. (1) Whether they represent good policy, however, is an open question. Many of these features are relatively new for Medicaid. But we have seen similar schemes in the past, in other arenas. The general notion that personal responsibility should be a more central part of welfare policy has been advanced by commentators such as Lawrence Mead, a key theorist in the "new paternalism" movement. Mead has argued for more than two decades that states with "moralistic" political cultures--generally speaking, those attuned to public welfare rather than individual interests, and those with a strong administration and a bent towards problem-solving--have been more successful in welfare reform than states with a more "individualistic" or "traditionalistic" bent. (2) A key feature of welfare reform in moralistic states, according to Mead, is a strong emphasis on making welfare recipients responsible for their own well-being. Such states "are willing to help the poor, but they also demand that they help themselves." (3) Mead's writings were a touchstone for the 1996 reform of cash welfare, and while they have not played an explicit role in the current Medicaid reforms, their influence appears to have lived on. (4) While aspects of Mead's theory are certainly original, his appeal to personal responsibility in the context of American social programs is anything but. From the sixteenth-century English poor laws to eighteenth- and nineteenth-century writings on how best to provide for the poor, we can trace a common sentiment that the government must extract work in exchange for welfare benefits or risk encouraging idleness and vice. (5) Neither Mead nor other theorists and lawmakers believed that the poor were undeserving of relief, or that society had no duty to provide for them--quite the contrary--but all believed that providing for the most basic needs of the poor without, in the process, literally "telling the poor what to do" merely fostered indigence and all the vices allegedly attendant upon it. (6) Consequently, their efforts sought not only to bestow the basic means of sustenance, but to change the way the poor lived. These strains are evident today in legal and administrative changes to Medicaid. Both the states and the federal government recognize that we cannot do without Medicaid; we simply are not willing to bear the moral and social ramifications of eliminating it. All states and territories participate voluntarily in the program. (7) Yet many states are seeking changes that impose paternalistic health requirements on beneficiaries at a greater rate that at any other time in the program's history. On its face, this trend may seem to have more to do with cost-cutting than with a resurgence of paternalism in welfare. …