I had the fascinating realization today that, despite helping to administer the Medicaid program, neither I nor many of my colleagues have ever been the recipient of Medicaid.  That is, administrators of the benefit are usually not among the beneficiaries.  One cannot help but wonder what the program would look like and how it would be different if it were administered by people who receive Medicaid benefits.  To be sure, there is a lot that works in Medicaid and a lot of things that don’t work as well.  Would the program work better if it were more, for lack of a better term, “grassroots”?

I am reminded of John Rawls’ notion of the “veil of ignorance.”  He proposed that the ideal way of fashioning a social contract would be to picture life as a game in which all social actors are players.  Before entering the game, each player is behind a kind of “veil of ignorance”; that is, he or she does not know what his or her position will be in the game.  Will they be rich or poor, male or female, etc.?  Rawls proposes that, in this situation, the players would agree to a set of rules that maximized that minimum position in the game, such that even the player who ends up worst off is still able to survive.  Essentially, the social contract would minimize the risk to each individual player by elevating the “floor.”  Not all players end up equal, but no one is destitute.

Maybe this is an approach that should be appropriated in thinking about Medicaid policy.  That is, design the rules from behind a theoretical veil of ignorance, imagining that even the architects of the program might end up becoming beneficiaries.  What difference would this make?  Would eligibility standards be eased or reimbursement rates higher?  It is impossible to say for sure.  But, it is an interesting thought experiment.