Show Notes
Medicaid was never intended to be the backbone of the U.S. public health system. But what started in 1965 as a limited health insurance option for a small group of low-income Americans has grown into a $900 billion program that funds everything from hospital care to housing support.
In this episode, Michael Sparer and Rebecca Sale trace the history of Medicaid and unpack the sweeping changes coming to the program under the “One Big Beautiful Bill.” The result won’t just be fewer people with insurance. It could also mean unexpected and harmful cuts to the country’s already fragile public health system. They also discuss whether a small, unexpected provision for rural health investment could point toward a better model for the future.
Michael S. Sparer, J.D., Ph.D. is the William Henry Welch Professor of Public Health Systems at Columbia University's Mailman School of Public Health, where he has taught for over 30 years. He also directs the Center for Public Health Systems, which examines how America's fragmented public health infrastructure functions and how it can better serve communities.
Professor Sparer’s research examines how policy shapes politics both in health insurance systems and in local health departments. He is particularly expert in Medicaid policy and in the inter-governmental dynamics that have shaped the evolution of that program. His work on public health has also focused on federalism and on the ways in which local health departments respond to changing political and fiscal environments. Before his academic career, he spent seven years as a litigator for the New York City Law Department. He is a three-time recipient of Columbia teaching excellence awards and former editor of the Journal of Health Politics, Policy and Law.
The Center for Public Health Systems at Columbia's Mailman School of Public Health conducts needed research, facilitates public discussions, develops policy proposals, and provides educational programs, all with the goal of encouraging a better, more efficient, and more equitable public health system. This work builds on the recognition that the nation’s public health system is currently under-resourced, under-paid, and under-valued and that a stabilized and strengthened system would benefit all of us.
More from Who the Health Cares? with Prof Michael Sparer
Welcome to season three of Who the Health Cares from the Center for Public Health Implementation at Columbia University.
Public health funding is often discussed as a matter of budgets and policy. But the real story is about politics, relationships and power. In the aftermath of the COVID-19 pandemic, states across the country received an unprecedented influx of federal dollars to strengthen their public health systems. But turning those investments into lasting change proved far more complicated than simply appropriating money.
Public health officials are navigating an increasingly complicated landscape defined by shrinking resources and political polarization. Meanwhile, artificial intelligence is transforming how health systems collect information, manage care and respond to community needs. The challenge for today’s public health leaders is figuring out how to adapt without losing the public’s trust or losing sight of their core mission: improving the health of the communities they serve.
The work of public health often becomes most visible when our systems are under the greatest strain. From hurricanes to pandemics, crises test not only our ability to respond, but also the strength, flexibility and fairness of the systems we rely on every day.
The work of the U.S. public health system is invisible to many of us. That’s why public health guidance is often misunderstood – and ultimately mistrusted – by Americans on both sides of the political aisle. And in times of uncertainty, when clear guidance matters most, the gap between perception and reality is especially costly.