Introduction

An entitlement is a governmental benefit to which a person is legally entitled if they meet certain eligibility criteria.  For example, if an individual is accused of a serious crime and is unable to afford an attorney, he or she is entitled to legal representation at public expense.  Similarly, an individual who loses their job may be entitled to unemployment compensation from the state in which they reside.  A third example would be that of an elderly person living in the United States who is entitled to an old age pension and healthcare benefits from the federal government in the form of monthly Social Security payments and Medicare benefits.

Entitlements play a very important role in the promotion of sustainability in several ways.  First, social and economic justice is a core element of sustainability.  Sustainability entails more than just survivability — it is survivability within the context of an equitable social, political, and economic value structure.  In modern democratic societies, the value structure providing for an equal voice in elections and equal protection under the law points us in the direction of fairness in the distribution of goods and services (often expressed in terms of the “social safety net” concept).  The challenge of promoting sustainability into the future will bring us face-to-face with issues of limited resources again and again, and the difficult tradeoffs to be made between the economic vitality, environmental protection and social equity core values of sustainability will require the utmost care and skill to manage.  The nation’s state and local governments, and the citizens of the communities involved, will be called upon to engage in this difficult tradeoff management process repeatedly in the coming decades.  Given the importance of this area of concern to every community, this chapter is included in this book as a key element of the study of state and local government.

Background and Types of Entitlements

While virtually all observers of modern democratic countries would agree that entitlements are essential to good governance, it is also the case that the boundaries of discussions related to governmental entitlements are often unclear.  In part, this is due to the ever-changing conceptualization of the nature and proper scope of entitlements.  Public health protection, for instance, once meant principally that government authority was used to isolate individuals who were infected with communicable diseases via quarantine.  In some cases, such persons were simply left to die in isolated asylums.  Similarly, assistance for the chronically unemployed often revolved around private charity, almshouses and public begging in designated places.  These examples from the past may appear quaint or laughable to many Americans today, but they were the most common forms of public health and welfare promotion practiced in this country in the not-to-distant past.  As the demographics of our state and local government populations have changed, our collective understanding of entitlement has changed – either becoming broader in scope or more exclusive of client eligibility.  This chapter will highlight a few basic entitlements associated with sustainable communities and illuminate some of the dynamics associated with expanding and contracting conceptions of governmental entitlements.  The chapter will identify some areas of likely entitlement growth and highlight some areas where governmental entitlements might become more limited as our society seeks to promote sustainability.

Meanings of “Entitlement.”

In his 2004 Columbia Law Review article, “The Political Economy of Entitlement,” legal scholar David Super outlines six principal definitions of entitlement (Super, 2004):

1. Subjective entitlement:  This represents a belief that an individual has certain benefits due them, regardless of whether a legal foundation for that belief exists.  Politicians will sometimes use phrases such as, “everyone has a right to own a home” even if there is no legal foundation to the statement.
2. Unconditional entitlement:  According to Super, this represents a “benefit that is not subject to conditions or reciprocal obligations.”  As Super correctly notes, most governmental entitlements are conditioned upon some aspect of reciprocal obligation.  For example, a person receiving unemployment benefits must have been previously employed and been part of a layoff and must be looking for a job actively to continue to receive benefits.
3. Positive entitlement:  This represents “a legally enforceable individual right.”  This is the most familiar definition of entitlement.  Individuals have a form of property right attached to a positive entitlement, such that an illegal depravation of such an entitlement provides ground for a lawsuit based on the suffering of a substantive harm.
4. Budgetary entitlement:  The concept is often referred to as “mandatory spending” in the law.  Social programs that are budgetary entitlements are prioritized above all other expenditures in that they are not subject to caps on spending.
5. Responsive entitlement:  These governmental expenditures are made based on a need-based formula.  Public education programs driven by student headcounts are an example of a responsive entitlement; government payments to the victims of natural disasters would be another example of this type of entitlement.
6. Functional entitlement:  There are some governmental programs that meet “some qualitatively definable need of its beneficiaries.”  Super argues that many food and nutrition programs assume that “healthful sustenance” will be accomplished for a person if a certain food and nutritional benefit level is established.  His example in this area is food stamps — a certain benefit level is established with the idea that a recipient household’s food needs will be met.

Super’s distinctions drawn in his effort to define the concept of governmental entitlement are valuable, helping us to understand what it is we mean by entitlement and, thinking normatively with respect to ‘good’ and ‘bad’ forms of government entitlement, what entitlements should be maintained to promote sustainability in the communities served by American state and local governments.  In many cases where the major state and local governmental entitlement programs are discussed it will be clear that several of Super’s subtypes of entitlements might apply to any specific policy discussed.

In contrast to Super, John Skinner provides a greatly simplified approach to thinking about entitlements (Skinner, 1991).  He distinguishes between only two forms of governmental entitlement; those being earned and those being implied.  According to Skinner, Social Security is an example of an “earned” entitlement because one contributes a portion of one’s earnings to Social Security and the level of contribution directly affects the level of benefit received.  In contrast, Medicare is an example of an implied entitlement because it is assumed that once one reaches retirement age one is entitled to Medicare health benefits regardless of one’s contribution level through payroll deductions over a career and regardless of your extent of need.

Entitlements and Sustainability

While the social justice and equity concepts underlying governmental entitlements are rather evident, it must be noted that the cost of providing entitlements is tremendous.  As a percentage of total costs, state and local health and public assistance programs consume a substantial portion of state and local government budgets.  Critics of “social spending” argue that if existing health entitlement programs are left unchanged, they will consume an ever-growing portion of state and local budgets, thus limiting the ability of government to allocate resources on other important needs (Baicker et al., 2008; Howe, 2017).  One solution proposed by critics is to thoroughly reform the current public assistance and health care entitlement programs; to judiciously trim costs where possible, and to adopt “best practices” and innovative programs to more effectively target health and public assistance funds.  Another approach to reform in this area is the promotion of investments in prevention of illness and early screening and diagnosis, hence achieving cost containment via citizen wellness practices and early treatment of preventable illnesses.  In the 1990’s, state and local governments across the country took the lead in reforming existing public assistance programs and placing limits on welfare eligibility and promoting active re-engagement in the workforce for many recipients (Malpass, 2007).  The result was a precipitous decline in the number of welfare recipients in nearly all states.

From the perspective of the former welfare recipients, many of them benefited from welfare-to-work programs; however, simply getting individuals off from welfare rolls and into the workforce is not the end of the sustainability story when it comes to entitlements (Moffit, 2002).  In the case of welfare reform, one of the biggest issues facing former public assistance recipients beyond employment is the difficulty of maintaining and improving existence; for example, balancing new employment with the need for quality childcare (Moffit, 2002). The stresses and strains of life off from the welfare rolls after years of dependence often prove to be too much all at once, and the ability to deal with these pressures comes at time when the costs of services is rising and the range of family needs (e.g., access to cable TV and the Internet) is growing.

One of the areas of entitlement that was almost immediately affected by welfare entitlement reform falls under the health care policy arena.  The meteoric rise of expenditures for health care entitlement programs such as Medicaid and S-CHIP, for instance, are frequently bewildering to the average citizen.  Why should health care cost so much?  What are the health care professionals doing with all the money?  These questions may prove maddening until one understands what the term health care really means.  Unfortunately, health care conjures up many out-of-date images.  One image is the clean hospital bed with the considerate and caring nurse attending to the young patient with tonsillitis.  Another image is that of the physician examining the expectant mother.  Perhaps another image is the kindly country doctor listening to a man’s heartbeat with a stereoscope.  These are all very appealing images; however, not one of them accurately captures the direction and scope of health care today…and perhaps they never did capture the true meaning of health care.  Nonetheless, the myth of health care derived from the long-gone past proves persistent.  Ever-increasing “standards of care” in the medical professions reflecting advances in medical science and pharmacology and the availability of newer diagnostic tools (e.g., MRI and CT scanning) are all advances in care which carry very substantial costs.

In the U.S., health care policy has been tied closely to issues of national defense, macro- economics, urban planning, immigration, an aging population, class-based inequities, minority race/ethnicity disadvantages, and a whole host of other political issues in dispute.  National programs in health care began as early as the 18th century with the Marine Hospital Service.  Community-level health care initiatives were primarily privately managed until the late 19th century when large-scale immigration resulted in rapid urbanization and industrialization (Rosen, 1993).  Major epidemics such as a cholera outbreak in New York City led to the widespread creation of public programs for sanitation and health care in state and local governments across the entire country (Rosen, 1993).  As our society has continued to urbanize, the need for such programs has increased tremendously.  Health care has progressively come to be viewed as a benefit not only to the individual receiving health care services, but also to the community as a whole.  Healthy people provide a good workforce, they spend more time in productive activity than when under medical care, and they occasion less need for collective resources to be devoted to the provision of health care services for the indigent.

In sustainable economies of the future, all elements of production must be able to work in unison; healthy workers are a critically important part of the economic enterprise.  Beyond work, there is the issue of healthy children.  As a society, we commit a tremendous amount of money and time to educating and caring for young people; proper investment in the future is, after all, a critical dimension of sustainability.  Children who are not healthy are unable to benefit from education and will likely develop other physical ailments that adversely affect their social and economic potential.  Technology has made us more aware of new and growing issues related to pre-natal and child health care.  Problems such as birth defects and autism can be treated if diagnosed early, and those conditions can be medically managed far better today than was the case in the past.

As the Baby Boomer generation ages, an increasing proportion of our governmental resources will necessarily be spent on medical needs.  A sustainable community, facing this known pending demand on its resources, must be both compassionate and pragmatic.  The demonstration of governmental compassion for the elderly and infirm is very important to building inclusively within society and to promoting social justice.  Pragmatically, a sustainable community is aware of the great benefit of maintaining a healthy and productive population.  Older, often richly experienced individuals often bring with them economic resources (e.g., skills, social networks, accumulated wealth, etc.) that can help local economies and generate gainful employment.  Older individuals often have substantial intellectual capital gained from years of experience in the workforce; through the employment of these retirees into new professions, this intellectual capital can be tapped to improve society.  Disabled individuals often possess many valuable skills and knowledge that is all too frequently “lost” to society and to the individual when physical limitation separates them from the larger community (Li, 2023).  While many of these individuals receive some level of federal health care benefits, there are a substantial number of disabled individuals who, in midlife and early older age years, would remain inaccessible if it were not for state and local government health resource entitlements.  Health care for the elderly, therefore, is particularly critical to enhancing community sustainability.

The very meaning of the word “healthy” has changed substantially.  One could have perfect physical health — e.g., normal blood pressure, cholesterol, heart rate, and eyesight — but suffer from severe mental health maladies.  Health issues related to depression, bipolarism, and personality disorders have long existed in society.  However, in the past individuals had little or no access to health care solutions for the problems of mental illness.  What solutions did exist often involved institutionalizing individuals in sanitariums rather than helping them to remain within the general community and achieve a productive and respected role in society.  Effectively addressing the problems of mental health has become an increasing important matter for state and local governments in the United States as the size of the population affected and the problems arising from mental illness for society have become increasingly evident (National Alliance on Mental Illness, 2023).

The stresses of the school setting, the workplace, and living in general under the conditions of the threat of terrorist attack and prospects of global climate change have become overwhelming for many individuals and the families within which they live.  Work schedules have become extended with the advent of low-cost computers and advances in communication technology, changing the boundaries that once separated office and home settings.  The itinerant nature of contemporary society and the high technology world tend to separate people from one another rather than bringing them together.  The aging of the U.S. population in many cases means that older individuals have either become separated from their families or, alternatively, have become so reliant on their relatives that social and economic strains begin to appear within caregiver families.  Health care issues, then, clearly extend to problems previously known, such as mental health, but all too frequently ignored as a matter of active governmental concern.

As a final example, the issue of substance abuse is a growing public health care concern.   In the past, substance abuse was assumed to be the rational choice of individuals — addiction and possible death as a result was viewed as the price one paid for a bad personal choice.  A sustainable community, however, cannot rationally make the choice to simply ignore problems associated with substance abuse and drug addiction.  Philosophically, societies agree to care for their members.  Practically-speaking, it is a serious drain on society to simply let the forces of drug addiction and substance abuse sap the strength of the community.  In all state and local government settings drug addiction and substance abuse prevention and treatment have become important aspects of health care (and the criminal justice system).  Substance abuse problems cross age, gender, and ethnicity boundaries.  While substance abuse among the youth remains troublesome, there is evidence to indicate that the rate of substance abuse is either leveling off or declining among this sub-population.  A rising trend, however, is the incidence of substance abuse among Baby Boomers (Cleary et al., 2017), that will likely require local communities to refocus their substance abuse efforts on this demographic group.

Public assistance and health care are closely intertwined, and both areas constitute an important part of a dialogue on sustainability.  Termed entitlements, policy programs falling under the auspices of public assistance and health care are far-reaching and have inspired a next generational perspective on social programs designed to address public assistance and public health problems.  Many of the governmental programs previously discussed in terms of entitlements — the implication being that there are narrowly defined givers and receivers of benefit — are increasingly discussed in terms of “community” assistance and health-promotion programs.  The new perspective to be discussed next recognizes that the entitlement of yesterday is more properly seen as a collective community commitment or investment made to proactively address shared needs, and that this collective response to public assistance and public health needs benefits local communities as a whole.

Public Assistance

In 1996, a bipartisan coalition of Senators and Representatives in the U.S. Congress passed the Welfare Reform Act and President Clinton signed the act into law.  With an eye to achieving outcomes similar to those associated with the state and local welfare reforms of the prior decade, the Republican majority in Congress hoped to eradicate one major element of the “welfare state.”  The state and local welfare policy reforms preceding the 1996 Act generally tightened eligibility requirements for recipients and placed time limits on the length of time one could receive welfare benefits.  After over a decade of experience with the welfare reform movement, we can say with some confidence that the 1996 act represents the beginning of a change in American thinking about what public assistance as an entitlement might mean in a new millennium.  The new target of public assistance is less the individual recipient of the benefit than it is the local community as a whole.

Temporary Assistance for Needy Families (TANF)  is the primary federal policy on public assistance in the United States.  As a result of the 1996 Welfare Reform Act, TANF replaced Aid to Families with Dependent Children (AFDC).  A block grant program, TANF requires states to develop specific public assistance plans to reflect state and local values, but within the general TANF requirements.

The Office of Family Assistance (OFA), Administration on Children and Families (ACF), a unit within the U.S. Department of Health and Human Services (HHS), is the federal office which oversees TANF block grant dispersals and oversees state policy requirements to determine if they meet TANF eligibility guidelines.  With the 1996 federal statute as the primary guideline, OFA outlines four major goals for the TANF program (Office of Family Assistance, 2022):

• assisting needy families so that children can be cared for in their own homes
• reducing the dependency of needy parents by promoting job preparation, work, and marriage
• preventing out-of-wedlock pregnancies
• encouraging the formation and maintenance of two-parent families

The TANF program imposes a lifetime limit of five years on individuals receiving federal TANF funds.  States can set shorter or longer limits, but no more than 20% of the state’s welfare caseload can exceed the five-year federal limit.  States that wish to extend benefits beyond this period using their resources are permitted to do so at their own discretion.  Proponents of TANF argue that these time limits provide states with the flexibility to tailor public assistance programs to their specific needs.  However, critics contend that states with the highest levels of need may struggle to self-finance extended welfare benefits, lacking the necessary federal, state, or local revenue to adequately support their citizens and local communities in need of this form of assistance.  This highlights the ongoing debate regarding the balance between state flexibility and the adequacy of funding for vulnerable populations.

Table 12.1 TANF and MOE Spending and Transfers by Activity, FY 2022: United States Total Funds = $31,342,645,652

Source: Office of Family Assistance, Administration for Children and Families, 2023.

TANF requires that recipients meet work requirements unless approved waivers are granted by state and national TANF administrators.  Two-parent families must work 35-40 hours per week, while single parent family work requirements are 30 hours per week.  Certain exceptions are made for single parents who have children under six years of age who cannot find adequate childcare, and thus cannot balance their employment requirements with extant childcare responsibilities.  “Work” may constitute full time employment in salaried positions, but may also include participation in employment training programs, on-the-job training, civic service activities, or even successful participation in formal secondary education.  Proponents of TANF argue that the work requirements are broad enough to provide TANF recipients the opportunity to gain skills necessary for financial independence post-assistance.  Criticism of the work requirement generally focuses on the potential for limited access to the full scope of “work” activities in states and local communities.  Ultimately, post-TANF program participation gainful employment must be found; unfortunately, in communities lacking employment opportunities TANF recipients are faced with little hope for the future after their benefits have expired.  TANF does make accommodation for states to create jobs directly or provide job incentives for private employers so that TANF recipients will have a greater chance of obtaining gainful employment when their eligibility expires (Office of Family Assistance, 2022).

TANF monitors all U.S. state programs to determine if the federal statutory requirements associated with the program are being met.  If a state fails to meet these requirements, then TANF grant amounts to the state can be reduced administratively.  Because of these strong sanctions, state reporting requirements are quite stringent.  Proponents of TANF, including the conservative think tanks The Heritage Foundation and the American Enterprise Institute, argue that reporting requirements keep states in line with the national goal of streamlining the program and moving welfare recipients into the workforce.  Critics of TANF, including the progressive think tanks Center on Budget and Policy Priorities and the Economic Policy Institute, argue that reporting requirements excessively limit each state’s ability to be innovative and responsive with public assistance programming to meet state and local needs.  Despite these complaints, however, it is indeed clear that state and local governments in the United States have a considerable latitude in crafting public assistance programs for both individuals and the communities within which they reside because of the permissive 1996 Welfare Reform Act provisions replacing far more restrictive requirements of the AFDC program..

TANF requires states to allocate a certain percentage of their own funds to support public assistance efforts, referred to as Maintenance of Effort (MOE).  The MOE is calculated based on the amount of money spent by the Administration for Children and Families (ACF-TANF) in each state.  States must meet MOE requirements to qualify for federal TANF funds, ensuring that state spending on public assistance does not fall below a specified threshold.  States can also make separate voluntary MOE commitments beyond the required amount, which can vary significantly based on state budget priorities and economic conditions.  From 2000 to 2004, the rate of annual increase in state MOE allocations grew considerably, reflecting heightened state contributions to public assistance programs.  However, this growth rate declined in 2005 and 2006 in real dollar terms.

Since 2008, there have been notable trends in the number of children receiving TANF payments.  After peaking in 1993, the number of children on AFDC/TANF fell significantly.  The data up to 2014 showed this decrease, but it did not stop there.  Post-2014, there have been fluctuations, often influenced by economic conditions and policy changes.  According to recent data from the U.S. Department of Health and Human Services (HHS), the number of children receiving TANF assistance continued to show a declining trend, reaching approximately 2.3 million in 2019 (U.S. Department of Health and Human Services, 2024).  This decline has been attributed to various factors, including stringent eligibility criteria and work requirements. Despite this reduction in caseloads, the proportion of children in poverty receiving TANF benefits has also decreased, highlighting concerns about the program’s reach and efficacy in addressing child poverty.  As of the latest reports, the percentage of children living in poverty who receive TANF benefits remains low, reflecting ongoing challenges in the program’s accessibility and support for low-income families.

The COVID-19 pandemic caused a temporary spike in TANF applications and recipients, as more families faced economic hardship due to job losses and reduced incomes.  However, this increase was not as substantial as might be expected, partly due to the availability of other forms of federal assistance such as enhanced/extended unemployment benefits and stimulus payments.

In summary, while the overall trend has been a decline in the number of dependent children receiving TANF benefits, economic conditions, policy changes, and the availability of other assistance programs continue to influence these numbers.  The ongoing debate about the effectiveness and reach of TANF highlights the need for continuous evaluation and potential reforms to better support those families in need.

Health Care

Whereas it can be said with some confidence that welfare reform is showing some progress towards flexible adaptation and proper orientation toward sustainable community development in state and local governments across the country, health care largely remains an unresolved issue in many states and local communities.  Health care entitlement programs continue to be a central point of political debate, and they played a significant role in the 2020 presidential election.  The urgency for health care reform in the United States remains, with serious efforts needed to streamline service delivery, enhance the quality of care, especially in early diagnosis and preventative care, and control rising costs.

While significant advancements have occurred in American health care services for those with insurance, substantial efforts are still required to extend this access to the uninsured.  As of 2023, the U.S. Census Bureau (2023a) reported that approximately 27.5 million individuals in the U.S. remain without health insurance, reflecting the ongoing challenge of achieving universal coverage. Particularly concerning is the coverage gap for the nation’s youth, many of whom are not covered by parental health insurance and typically have inconsistent access to state insurance programs. This gap results in the loss of preventive medicine benefits and early illness diagnosis for a substantial segment of the population essential to the sustainability of local communities.

Efforts to improve health care access and affordability continue, with initiatives at both state and federal levels aiming to address these troublesome disparities.  The expansion of Medicaid under the Affordable Care Act has helped to reduce the uninsured rate, but ongoing political and legal challenges underscore the complexity of achieving comprehensive health care reform in the U.S.

The United States is facing significant challenges with an aging population, particularly as the Baby Boom generation enters retirement.  This massive demographic shift is the most substantial factor driving up costs in health entitlement programs, similar to the trends seen in other developed nations (U.S. Census Bureau, 2023b).  However, the U.S. healthcare system also faces other issues not directly related to the aging population.  These include a rising prevalence of childhood obesity and diabetes, and the need to address mental health, substance abuse, and drug addiction issues (U.S. Department of Health and Human Services, 2023).  Additionally, the structure of American families has evolved, with more single and divorced parents encountering various health challenges for themselves and their children (U.S. Census Bureau, 2023b).

Currently, three primary health care entitlement programs impact state and local governments significantly: Medicare, Medicaid, and the State Children’s Health Insurance Program (S-CHIP) (U.S. Department of Health and Human Services, 2023).  These three programs provide critical support, but also impose considerable financial burdens on state budgets due to rising healthcare costs and increasing levels of demand for services.

Medicare is a federal health care program for the elderly.  Medicaid is a state program, cooperatively managed at the state and federal levels of government to meet the health care needs of low-income individuals and families.  S-CHIP, or the State Children’s Health Insurance Program, is also a state program, cooperatively managed at the state and federal level, intended to meet the health care needs of uninsured middle- and low-income children.

Medicare

While a national program, Medicare is an important part of maintaining sustainable state and local communities.  The Medicare plan provides for the health care needs of individuals 65 years of age or older.  Recognized Medicare program health care providers privately supply health care under Medicare.  There are three major components to medical coverage:

• Part A — Hospital Insurance: Part A covers specified costs of hospitalization, nursing care facility stays, home health care, hospice care, and blood transfusions for patients staying in the hospital or during covered stays in a skilled nursing care facility.  However, Medicare does not cover all costs of every medical procedure.
• Part B — Medical Insurance: The Medicare program covers a percentage of Medicare-approved procedures.  Costs that exceed those covered by Part B are the patient’s responsibility.  Patients may choose to enroll in private health insurance plans to cover additional expenses or opt for the government sponsored Medigap insurance program.  Expenses not covered by either private insurance or Medigap are the responsibility of the patient.
• Part D — Prescription Drug Program: The prescription drug program covers expenses for various generic and brand-name drugs.  The patient’s co-payment will vary depending on the type of drug prescribed.  Medicare Part D coverage limits the amounts of drugs dispensed at any given time.

The oldest members of the Baby Boom generation are now in their 60s, close to retirement, and becoming increasingly susceptible to the infirmities of age.  By 2030, it is estimated that there will be 2.7 workers for every retiree drawing health and retirement benefits.  Clearly, economic sustainability is potentially challenged by a growing tax burden and budget constraints.  The sustainability of the Medicare program, as it currently exists without significant change, is highly dubious.  Either a reduction in benefits or changes in eligibility might be necessary to make the program viable for future generations if no alternative health care financing system is created.  These policy changes at the national level, however, will not reduce the expanding health care needs of the elderly. Preventative care, ”wellness”-focused health practices, and effective outreach to at-risk populations are all important ways of limiting health care needs and economizing on health care expenses. Regular exercise and balanced diets are important to maintaining good health, and avoidance of smoking (and exposure to second-hand smoke environments) and moderation in the use of alcohol are likewise important means of reducing health care costs.  Public-private partnerships involving national, state, and local government are critical to making available the wellness information, healthful foods, and exercise facilities needed to stay healthy and providing access to geriatric nutrition information for the elderly (U.S. Census Bureau, 2020; U.S. Department of Health and Human Services, 2022).

The health care entitlements of Medicare are of critical importance to the health status of the nation, but they will likely fall short in providing for many of the basic everyday needs of the elderly.  While the Administration on Aging, Department of Health and Human Services, provides significant guidance for eldercare and endeavors to protect the elderly from abuse, most of the resources and energy needed to sustain a quality of life for our elderly citizens will come from the hard work, personal resources, and patience of private individuals living within our local communities.  Community eldercare is an important part of developing sustainability in our nation’s local communities.  A growing number of middle-aged adults are seeking to balance child-raising, career, and eldercare responsibilities for relatives and friends.  Many individuals already face these challenges, and more will do so in the coming years.  Cooperative effort will be necessary to cope with the added responsibilities, and “family friendly” workplace policies will be needed to accommodate the persons taking on these often burdensome caregiver roles.

Medicare, and its related health care programs for the elderly, provides a solid foundation for health care entitlement in the United States.  Sustainable eldercare, however, involves much more than health care dollars for hospitalization, health insurance, and prescription drug benefits.  The essential margins of health care sustainability for the elderly will most likely be provided by sustainable community-based eldercare; those communities which provide for the needs of both young workers and the elderly individuals for whom they care on a daily basis will likely prosper; those that leave their elderly to rely entirely upon the federal government’s Medicare program will experience serious dislocation as the Baby Boomers move into their early and late post-retirement years.

Medicaid

Medicaid, a cooperative health care program between the national and state governments, is designed to meet the medical needs of low-income individuals and families.  The following are the commonly associated standards for eligibility for Medicaid benefits:

• Families meeting the state’s AFDC/TANF eligibility requirements: Families who met the eligibility criteria for Aid to Families with Dependent Children (AFDC) as of July 16, 1996, or its successor, Temporary Assistance for Needy Families (TANF).
• Pregnant women and children under age 6: Pregnant women and children under the age of 6 whose family income is at or below 133% of the Federal Poverty Level (FPL).
• Children ages 6 to 19: Children aged 6 to 19 whose family income is up to 100% of the FPL.
• Caretakers: Relatives or legal guardians who take care of children under the age of 18 (or 19 if still in high school).
• Supplementary Security Income (SSI) recipients: Individuals receiving SSI who meet certain additional requirements.
• Institutionalized individuals and couples: Individuals and couples living in medical institutions with a monthly income up to 300% of the SSI income standard.

In addition to these standards, states can establish their own eligibility requirements.  Individuals who qualify for Medicaid receive hospitalization, insurance, and drug benefits quite similar to those received by Medicare recipients.

Medicaid is a very important program with respect to advancing sustainable states and local communities.  Without the benefits provided under the Medicaid program, a great many low-income individuals would have extremely limited access to health care.  In many cases, low-income individuals are the virtual backbone of a sustainable community, working in low salary jobs in the agricultural, service and production industries.  Increasingly, private sector employers are eliminating employer-provided health care benefits for their workers, leaving low-income workers and their families in a highly vulnerable position.  Without access to health care, worker absenteeism tends to be high and productivity low; undiagnosed illness, which could be treated inexpensively if detected early, frequently become acute and require extremely expensive emergency treatment and hospitalization.  Poor access to health care for children has a particularly depressing effect upon their school attendance and learning.  Sustainable communities will require high levels of employee productivity and the production of high-quality goods and services, and they will require that children are making adequate progress in their education.  Health care entitlement programs, such as Medicaid, represent a critically important societal commitment to low-income individuals and the sustainability of the local communities in which they live and work.  The Medicaid program is a quintessential illustration of how the “social safety net” connects directly to the promotion of sustainability.

Medicaid is a significant financial burden on state governments despite its direct benefits in promoting sustainable communities and addressing health care concerns for low-income individuals. Since the early 2000s, Medicaid enrollments increased substantially.  Between 2000 and 2004, enrollments grew by 28%, from 42.8 million to 50.1 million individuals.  The financial impact was even more pronounced, with health care payments increasing by 53%, from $168.4 billion to $257.2 billion during the same period (Medicaid, 2024).  Despite these rising costs, studies by Kronick and Rousseau (2007) suggest that, with effective cost management and modest reforms, Medicaid remains sustainable.  Streamlining the delivery process and reforming reimbursement schedules are key strategies believed to enhance the program’s viability.

Community health centers play an important role in developing sustainable community health programs, particularly in rural areas lacking accessible hospital facilities. These centers offer a range of essential services, including primary health care, dental and mental health services, and supportive services like nutrition education, translation, and transportation. By providing comprehensive and culturally appropriate care, community health centers can significantly improve health outcomes and reduce healthcare costs by minimizing avoidable emergency room visits and hospital-based care.

In rural settings, community health centers are vital for serving populations such as farmers, ranchers, and farm laborers, who might otherwise face significant barriers to accessing health services. In urban areas, these centers help reduce the burden on emergency rooms by offering urgent care facilities that provide immediate, cost-effective treatment.  The importance of these centers has grown over the years, with notable expansions during both the Bush and Obama administrations, supported by funding from initiatives such as the American Recovery and Reinvestment Act of 2009 and the Affordable Care Act of 2010.  These expansions have led to significant increases in the number of health centers and the scope of services provided.  For example, between 2010 and 2016, the proportion of health centers offering mental health services grew from 73% to 87%, and those providing dental care increased from 76% to 80%. Community health centers have been shown to save the U.S. healthcare system between $9.9 billion and $24 billion annually by reducing the need for more expensive hospital-based care (Rosenbaum et al, 2018; Whelan, 2010).

Community health centers serve as important cost-effective hubs for preventative care services.  Child immunization services and health screening can be done quite effectively in community health facilities.  Health education classes can be taught in community health centers for both the young and the elderly.  Drug and alcohol dependency programming are also important parts of community outreach services to be coordinated through community health centers.  In essence, community health centers represent the widespread recognition in urban and rural areas alike that sustainable communities require high quality health care provided through a variety of means.  Wellness and good health practices are seen as both individual benefits and community benefits rather than as commodities to be purchased solely by those individuals who can afford it (Rosenbaum et al, 2018; Whelan, 2010).

Community health centers could play a crucial role in addressing existing disparities in Medicaid patient care provided by private commercial providers.  Research conducted in this area indicates that Medicaid patients treated by commercial providers often receive lower quality care compared to privately insured patients in the same programs (Wilk et al., 2017).  These centers can offer a more consistent quality of care and may be better equipped to handle the unique needs of Medicaid populations, given their focus on serving underserved communities (National Association of Community Health Centers, 2021).

Moreover, community health centers could address the gap in integrating health and public assistance benefits with day care services for working mothers.  This integration is vital for enhancing the effectiveness of health and welfare programs.  Studies have shown that access to reliable day care significantly impacts the ability of working mothers to maintain employment, which is a key factor in improving economic stability and health outcomes for low-income families (Gennetian et al., 2020).  By providing comprehensive services that include health care and childcare, community health centers could offer a more holistic support system for low-income families, thereby enhancing the overall benefits of public assistance programs.

State Children’s Health Insurance Program (S-CHIP)

The S-CHIP program is a state and nationally funded program that began in 1997.  The program is intended to extend health insurance to children who would not meet the income requirements of Medicaid.  Eligibility for S-CHIP is a function of a child’s age, family size, and household income level.  The S-CHIP program serves children from working class and middle-income families.  This healthcare entitlement helps these families remain in the middle class and working poor categories — without this healthcare entitlement the eligible families would likely lose their socioeconomic status in the case of any type of serious medical condition arising for their children.  As with Medicaid, S-CHIP offers health insurance, emergency medical care, immunization programs, and a health-screening program.  S-CHIP also helps reduce the cost of adult health care by managing the healthcare needs of adolescents before their health problems become chronic and expensive to treat.

Childhood obesity, for instance, has led to serious concerns about the future healthcare needs of Americans.  Related to obesity, many children are being diagnosed with diabetes, which can lead to other serious health care issues, principally vision, renal, coronary and circulatory disorders.  Obesity itself can also lead to heart problems, stroke, and premature death.  Increasing access to medical testing, preventive treatment and information through the insurance resources of the S-CHIP program means that chronic health issues can be either prevented or effectively treated to forestall serious health consequences in many cases.

Since 2000, enrollment in the State Children’s Health Insurance Program (S-CHIP) has significantly increased.  In 2000, S-CHIP enrolled 3.36 million children, but by 2022 this number had grown to 6.9 million.  This marks a substantial increase of over 105%.  Similarly, expenditures have seen a dramatic rise, increasing from $1.93 billion in 2000 to $21.0 billion in 2022, reflecting a more than tenfold increase.  S-CHIP remains a vital program for middle-class families, providing essential health coverage to millions of children while posing significant challenges to state budgets due to its rapid growth (Medicaid, 2024; Williams et al., 2023).

Successful sustainable communities possess the capability of relying upon the ability of the individuals and families living in those communities to respond to changing conditions and needs.  S-CHIP helps working class families, whose relatively acceptable economic status could quite easily be transformed into economic devastation by the health care needs of their children should serious illness occur.  This program allows these families to maintain the slack resources needed to respond other changing needs, such as care for an elderly relative or to cover the costs of further education. Slack resources might also be used to help other community members in times of need — providing shelter and food for a neighbor who lost their home or suffered a medical malady that will require the support of their close friends.

Unemployment Compensation

A national government policy administered through and supplemented by the states, unemployment compensation represents a commitment made to address temporary economic dislocations. The program is funded at the national, state, and local levels, using a combination of sources of funds. It is intended to provide financial assistance to unemployed individuals through direct payments to be used to purchase many of the necessities of life. Unemployment compensation is an example of a policy commitment type of entitlement, recognizing that there are times when other members of our local and state communities are incapable of fending for themselves due to circumstances beyond their control.

The states and the federal governments have different roles in managing unemployment compensation. Federal government responsibilities include the following:

1. ensure conformity and substantial compliance of state law, regulations, rules, and operations with federal law.
2. determine administrative fund requirements and provide money to states for proper and efficient administration.
3. set broad overall policy for administration of the program, monitor state performance and provide technical assistance as necessary; and
4. hold and invest all money in the unemployment trust fund until drawn down by states for the payment of compensation.

State government responsibilities under this program include the following:

1. determine operation methods and directly administer the program.
2. take claims from individuals, determine eligibility, and insure timely payment of benefits to workers; and,
3. determine employer liability and assess and collect contributions.

Unemployment compensation is generally fixed at 26 weeks, although some states such as Massachusetts offer a 30-week initial compensation period. During periods of sustained high unemployment, where it is highly unlikely that an unemployed person would be able to regain employment, extended unemployment benefits are generally paid for an additional 13 weeks. Unemployment compensation tax money is collected from employers by state governments but is then deposited with the federal government under federal statutory guidelines.

Entitlements and the Core Dimensions of Sustainability

In the broadest consideration, the sustainability construct we are using in this book can be viewed as a requiring a rather inclusive discussion of the need to balance citizens’ rights and responsibilities in a society that relies less on resource extraction and environmental degradation, and more on the careful and wise use of the renewable resources available to all individuals.  Sustainability requires due consideration of the needs of today, but keeps in mind the needs and conditions of future generations.  For now, we are here — alive, thinking, speaking creatures.  One of the reasons that societies first formed was because individuals and groups of individuals tried to figure out a better way to amass and distribute the resources needed to make life bearable, and to increase the likelihood that their offspring and future generations would both survive and be able to improve their respective lots in life.

Viewed in the context of sustainability, entitlements focus our attention on both short term and long-term goals associated with community well being.  In the short term, entitlements are designed to meet the immediate objectives of providing for the educational, economic and social welfare benefits of individuals who are often unable to provide for themselves.  In doing so, entitlements provide for the long-term goal of making survival and improvement possible for the beneficiaries and for future generations of people living in that community.  In this sense, the entitlement programs discussed in this chapter touch directly upon the social and economic objectives of sustainability.

Reform efforts are bringing social safety net entitlements closer into line with the environmental and economic core objectives of sustainability.  The evolution of entitlements in the 20th century focused attention on the rights of the individual within society.  Many entitlement policies focused state and local government efforts on issues of social welfare for the indigent; policies designed to help those who had or who were currently suffering from the effects of historic racial, ethnic, and gender-based discrimination; and policies promoting equality in education.  The sustainability paradigm embraces these initiatives to promote social equity; however, sustainability promotion calls for a somewhat broadened view of rights and responsibilities.  Increasingly, the focus of our attention is on communal rights and the rights of nature.  Should community benefit and the environment, broadly defined, be considered in a discussion of entitlements?  The focus on such issues is so current that it would be foolhardy to decide how it will be decided in the end; nevertheless, it is a central part of the sustainability paradigm and would significantly change the way states and local communities consider the issue of sustainability in the governance process.

A major reason for writing this book in this way at this time is that the present generation of college students will doubtless be the deciding generation for this critical question.  If the core values of economic vitality, environmental protection, and social equity are to be achieved in our communities, the challenge of providing a sustainable set of entitlements as a collective benefit to all citizens will have to be met by those who manage our state and local governments and those citizens who take an active interest in the wellbeing of their communities – through participating in civic affairs, through volunteering in community organizations, and through doing their fair share to promote wellness and good health in their own lives and those of their family members.

The concept of individual rights and responsibilities is deeply embedded in the institutional arrangements of American state and local governance.  Liberal democratic governance was built around the idea of inalienable individual rights and the promotion and protection of individual freedom and equality, carried out within the confines of orderliness in civil society.  Notions of global justice and trans-generational justice, for instance, were likely not at the forefront of 17th and 18th century liberal democratic thinkers’ minds.  Nonetheless, the thoughts and words of our Founding Fathers and their predecessors continue to govern American political institutions.  A major challenge facing the leaders of state and local government today is that of incorporating into the American individual rights tradition sufficient regard for the thoughtful consideration of future consequences so that collective action can take place to preserve the social safety net as progress is made toward maintaining vitality in our economic activities and protecting our environmental heritage.

Current Trends in State and Local Entitlement Programs

Current trends in U.S. state and local entitlement programs reflect a complex interplay of policy changes, economic pressures, and social needs.  One significant trend is the increasing emphasis on work requirements and employment incentives within welfare programs.  States are modifying programs such as TANF to include stricter work requirements, aiming to promote self-sufficiency and reduce long-term dependency on government assistance.  These changes are often accompanied by support services such as job training and childcare, recognizing that employment stability is crucial for low-income families to achieve economic independence.

Another notable trend is the expansion and innovation in Medicaid programs (Simpson, 2020).  Many states are adopting Medicaid expansion under the Affordable Care Act (ACA) to cover more low-income individuals and families.  Beyond mere expansion, states are also experimenting with value-based care models to improve health outcomes and reduce costs.  This includes integrated care for mental health and substance abuse, which addresses the opioid crisis and other pressing public health concerns.  Telehealth services have also seen significant growth, especially during the COVID-19 pandemic, providing greater access to care for rural and underserved populations.

Housing assistance programs are also evolving, with a growing focus on addressing homelessness and housing instability.  State and local governments are increasing investments in affordable housing initiatives and supportive housing for individuals with disabilities or suffering from chronic health conditions.  Programs are being designed to not only provide shelter, but to also integrate services that help residents maintain stable housing and improve their overall quality of life.  This holistic approach aims to tackle the root causes of homelessness and reduce the societal costs associated with it.  Furthermore, there is a trend towards leveraging technology and data analytics to enhance the efficiency and effectiveness of entitlement programs.  States are using advanced data systems to better identify and serve eligible populations, prevent fraud, and streamline administrative processes.  These technological advancements are helping to ensure that benefits are delivered more quickly and accurately, improving the overall user experience for program beneficiaries.

However, there are also conservative “red” states where these programs are under great scrutiny and attempts to reduce and/or repeal existing services.  One of the most notable trends is the imposition of stricter work requirements for programs like Medicaid and SNAP.  States such as Arkansas, Kentucky, and Wisconsin have implemented or attempted to implement policies that require able-bodied adults without dependents to engage in work-related activities, such as employment, job training, or volunteer work, to maintain their medical benefits.  Proponents argue that these measures incentivize work and reduce dependency, while critics contend that they can lead to some gaps in coverage for vulnerable populations who struggle to meet these requirements due to various barriers such as lack of transportation or affordable childcare.

In addition to work requirements, some conservative states are reducing the duration and scope of benefits provided.  For example, the states of Florida and Missouri have shortened the time limits for receiving TANF benefits and have imposed more stringent eligibility criteria. These changes are often justified on the grounds of fiscal responsibility and the belief that shorter benefit periods encourage beneficiaries to seek employment more aggressively.  However, opponents argue that these reductions can exacerbate poverty and make it harder for disadvantaged families to achieve long-term economic stability.

Another area of restriction involves the tightening of eligibility verification processes. States such as Texas and Alabama have increased the frequency and rigor of eligibility checks for Medicaid and other assistance programs.  These measures aim to prevent fraud and ensure that only those who truly need assistance receive it.  While this can save state resources and enhance program integrity, it can also create administrative burdens for recipients, leading to potential disenrollment of eligible individuals due to procedural hurdles.  Furthermore, some conservative states are also implementing policies that restrict access to benefits for immigrants. Measures such as requiring proof of citizenship or lawful presence for Medicaid and other state-funded programs are becoming more common.  These policies are part of a broader effort to prioritize resources for U.S. citizens and reduce public expenditures on non-citizen residents (Ollstein, 2023).

Overall, the trend in conservative states to restrict entitlement programs aligns with a broader philosophy of minimizing government intervention in individuals’ lives and promoting personal responsibility.  While these policies aim to reduce government spending and encourage self-sufficiency, they also raise significant concerns about their impact on the most vulnerable populations, people who may face increased barriers to accessing essential services and supports. The debate over these policies continues to reflect deep ideological divides regarding the role of government in providing social safety nets for their citizens (Ollstein, 2023).

Conclusion:  The Relationship Between Entitlements and Sustainability

Governing for sustainability means that we are committed to one another in our individual and collective pursuit of a good society.  Part of commitment means ensuring that vulnerable individuals are offered assistance based on their needs.  The elderly, children, unemployed individuals and the poverty-stricken are four examples of groups who are vulnerable and who often require the special attention of society.  In sustainable governance, commitment is not about charity; it is about maximizing the opportunity of all members of society to contribute to the common welfare.  For the elderly, opportunity means the chance to live a good life and to contribute the wisdom of experience to the community — be it the shared knowledge of living through challenging times and experience implementing tried-and-true methods of meeting those challenges, or sharing child-rearing responsibilities for young adult family or community members who work full time.  For children, among the most vulnerable of any community’s residents, opportunity means the chance to grow up and mature into healthy, happy, and productive adults; reliable access to quality healthcare is a critical part of achieving this goal.  For the unemployed and the poverty-stricken, opportunity means the chance to regain the dignity associated with economic independence; the opportunity to experience gainful employment provides that dignity.

The concept of “entitlement program” is used here because it is a term that is most frequently associated with the programs described above; it is one that reflects a philosophically liberal tradition regarding the rights of the individual and the need for the state to promote social justice.  While the rights of the individual are critical in sustainable governance, the programs detailed here are equally important for the preservation of sustainable community existence.  A focus on sustainability, therefore, requires both policy makers and citizens to re-conceptualize the meaning of entitlements, painting for themselves a broader understanding of the use and value of such programs.  We are increasingly aware that we are all givers and we are all recipients of the benefits offered by such programs, and there is evidence that the entitlement policies of the United States are responding to this recognition.

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