Dr. Megan Edison has raised an interesting point about a “healthy behavior” provision in the Obamacare Medicaid expansion bill that was passed by the Michigan House and considered by the Senate.

Under the bill, enrollees would pay more unless they “demonstrate improved health outcomes or maintain healthy behaviors as identified in a risk assessment by their primary care practitioner.” Dr. Edison characterizes as “creepy” the requirement that doctors must track and report to the state whether their patients have met that standard.

The provision also shows how Republicans mistakenly framed the expansion in the same conceptual terms as post-1996 welfare reform. This is erroneous because Obamacare is not intended to be a welfare program in the same way as Temporary Assistance to Needy Families, to use the current bureaucratic term for what regular people call being “on welfare.” It's an entitlement, just like Medicare and Social Security.

In contrast, since 1996, cash welfare benefits no longer are an entitlement. Instead, they are conditional on recipients jumping through various hoops dictated by the state, including work and job-training requirements, with a four-year cap on how long someone can collect.

The public implicitly understands the conceptual difference between "welfare" and "entitlement." The 1996 welfare reform was all about separating these, and most people have no problem with requiring welfare beneficiaries to jump through those hoops.

In the public mind, Medicaid falls somewhere between. As a practical matter it’s more like an entitlement, because in the end, Americans will not accept a system that requires them to step over the ailing bodies of individuals who could be cured if only they could afford treatment. Still, the public has generally been willing to impose some conditions on Medicaid beneficiaries.

Here’s how this is relevant to Obamacare-driven expansion of the program by the Michigan Legislature: Because Medicaid is now a critical component of a new entitlement, the conceptual framework for it has changed, especially for the above-poverty population covered by the expansion. Medicaid has been transformed into the lower rungs of the Obamacare entitlement ladder.

To grasp the significance, imagine the uproar if Republicans in the Michigan Legislature tried to impose healthy behavior conditions on middle class Social Security and Medicare recipients.

If Obamacare survives, then all the above has huge (and corrupting) implications for Americans’ relationship with their own government.

In the short term, it means efforts by Michigan legislators to extract federal permission for substantive Medicaid "reforms" as a condition for accepting Obamacare’s expansion of the program are based on an obsolete conceptual framework. As such, they are likely to go nowhere in Washington.

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