Clinical Governance: An International Journal

Purpose – This paper aims to summarize significant changes in Medicaid, a safety net health insurance program on which one in five Americans depend.

Design/methodology/approach – The paper takes the form of a narrative review.

Findings – During the same period that a downturn in its economy increased the number of uninsured and under-insured Americans, falling government revenues led to decreases in Medicaid coverage and a shift from administration by non-profit government to for-profit health maintenance organization entities. Hospitals in the USA scored as better managed than those of other countries in one study, but wide variation in local health service performance between and within its states also has been documented, and too many American families are foregoing needed care because of insurance and affordability problems. Whether shifting a public safety net healthcare system from public to private administration will make the situation better or worse has become the subject of political debate and court cases.

Originality/value – Perhaps masked by political party rhetoric focusing news attention on the future of the Patient Protection and Affordable Care Act (“ObamaCare”), America's public Medicaid system is increasingly being given over to control by private sector health maintenance organizations. This viewpoint article attempts to put that trend into perspective.