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...for low-income women. Rebuffed last year in its attempt to do so directly, through legislation converting the program into a block grant to the states, the administration has since turned to various backdoor approaches. While these approaches are generating opposition as well, the fact remains that calls for program cutbacks under the rubric of Medicaid "reform" are likely to be heard for a long time to come.

At the heart of the debate is Medicaid's status as an individual "entitlement" program--one in which any person meeting the program's eligibility requirements is legally entitled to enroll. Because of that fundamental organizing principal, Medicaid expenditures, which are shared by the federal government and the states, are not directly controlled by Congress and state legislatures, or even totally predictable. Instead, they rise and fall more or less automatically with the number of program enrollees--itself largely a function of overall economic conditions. Soaring enrollment during a prolonged period of national economic stagnation--while entirely expected given the basic design of the program--have nonetheless made Medicaid a major financial burden for the states in recent years ("States Eye Medicaid Cuts as Cure for Fiscal Woes," TGR, August 2003, page 6).

If at First You Don't Succeed ...

In 2003, the Bush administration made the cash-strapped states an offer it apparently felt they could not refuse. Taking on the individual entitlement to Medicaid directly, it proffered a legislative proposal to convert the program into a "capped block grant," under which each state would be provided a fixed annual allotment of Medicaid dollars. In return, the states would be given considerably more flexibility than they have under the current Medicaid statute to...

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