Medicaid was enacted in 1965, and it is a jointly funded, federal-state program designed to improve health care access for certain groups who demonstrate economic need. The federal government establishes certain minimal standards with which states must comply, such as eligilibility criteria, coverage mandates, and reimbursement methods; but states administer the program, and they have a great deal of discretion and authority to regulate all aspects of the program within these limits.

Generally, states participating in Medicaid have only been required to cover certain groups of people: people with disabilities, pregnant women, and children, with incomes below a certain level. Medicaid is also available as a supplement for low-income Medicare beneficiaries. (Medicare is the federal insurance program that covers the aged and people with disabilities).

Why only mandate Medicaid coverage for these groups? Historically, these groups were viewed as "deserving" -- they were seen as needing help through no fault of their own, and many felt that society had a moral duty to ensure their well-being. However, these eligibility criteria have long been criticized by health policy experts, patients' advocates, and many state and local lawmakers as too narrow.

First, they exclude categories of people who do not appear any less deserving of help. For example, our society values and encourages work, yet Medicaid has excluded nondisabled and childless adults who are capable of working and have worked, but were unable to get insurance due to no fault of their own. These groups tend to be priced out of the individual insurance market, and they often work for small employers, do seasonal work, or have part-time jobs that do not offer the more affordable group health insurance. Many of the "working poor" don't make enough to afford insurance even when it is provided.

Second, the notion that certain types of people are more deserving than others when it comes to health care access is a controversial and morally problematic basis on which to make policy decisions. Increasingly, we hear policy and lawmakers talking about how important it is that everyone have health care, and acknowledging the reality that rising costs create a significant barrier to care for people who want to buy insurance.

Finally, limiting eligibility for public insurance may save the government money in the short term, but it actually costs society much more in the long run. The uninsured are much less likely to get regular care that could prevent more costly and serious illness or disability. Inadequately managed care increases work absenteeism and interferes with one's mental ability to focus and be productive generally. And the uninsured are more likely to rely on emergency rooms for chronic illness that could be managed much more cheaply by a primary care provider, specialist, or outpatient center. Local governments, hospitals, and other patients bear this cost.

For these reasons, many states have already expanded Medicaid coverage beyond the required categores based on provisions in federal law that give states discretion to do this. Nonetheless, gaping holes in the public safety net still exist. The Medicaid expansion in the Act is good news because it helps patch up one of these holes. Beginning in 2014, all individuals under age 65 and with income up to 133% of the federal poverty level will be eligible for Medicaid coverage. This is important because even with the new insurance reforms and subsidies, this group probably will still not be able to afford private insurance.

Essentially, Medicaid is their "public option."