Jonathan Cohn makes an important point about Kerry's plan to expand Medicaid: "To the extent Kerry would have state programs gradually replace private insurance for these people, he's merely accelerating a process that is already underway." Indeed, according to the most recent Census data, Medicaid enrollment rose by 6.5 percent in 2003, even as the percentage of insured Americans declined. All Kerry wants to do is properly fund an ongoing trend.

At the same time, though, Medicaid has some serious flaws. Part of this comes from the fact that it’s a state program, not a federal one -- the wide fluctuations in enrollees tend to squeeze state budgets, especially during recessions. Meanwhile, costs tend to rise faster than state budgets, leading to cuts in services (since many states can't run deficits, even during downticks). But it's not very good as a health care program either, since it deals mostly with treatment rather than more cost-effective preventive care. But such is life. In an ideal world, Kerry would say, "Hey, people are naturally moving into public health care, so let's design a better public health care system." But here in the real world, its: "Hey, people are moving, etc., so let's just fund the system we have."