On Valentine’s Day 1966, Gov. Bob Smylie called a special session of the state Legislature to deal, primarily, with reapportioning the Idaho Senate to comply with the U.S. Supreme Court’s one-man-one-vote requirement. Back then, there was a senator for each of the state’s 44 counties, and the courts had ruled the arrangement unconstitutional.

So when Smylie gathered legislators under the dome, he was clear about priorities: reapportionment was the reason they were there. Other matters requiring attention while lawmakers were in town — purchasing real estate around the Statehouse and development of Farragut State Park — were secondary. Toward the end of his remarks, almost in passing, he mentioned the need for lawmakers to consider “adjustments to the public assistance law if we are to make its full benefits available to our people.”

What adjustments? The year prior, Congress had passed President Lyndon Johnson’s Great Society legislation. Among its provisions was a program we now call Medicaid. States were free to adopt, or not adopt, the program. If they did, the federal government would cover the majority of the bill for the health expenses of the poor and disabled enrolled in the program. 

In the following days and weeks, the Idaho Legislature adopted those public assistance changes with little apparent deliberation. The House voted 68-7 in favor of House Bill 14. The Senate voted 39-1. The newspapers of the time say little else about the debate.

It is worth sitting with that for a moment. Because, as we know now, Medicaid would eventually become the largest program in all of state government — larger than public schools when state and federal funds are totaled. It serves roughly one in five Idahoans today. It shapes how hospitals are built, how physicians practice, how billing for services is done, how nursing homes operate, and how mental health services are delivered across the state.

Little, if any, of that was contemplated in 1966. You would not imagine it from the text of Smylie’s speech, nor from the way newspapers covered the bill’s passage. The program was adopted not through serious public deliberation, but almost as an administrative footnote to a session called for an entirely different purpose.

As the economist Thomas Sowell has observed, there are no solutions — only tradeoffs. 60 years of Medicaid participation have come with real ones, and Idaho’s policymakers have rarely named them. Not at the outset. Not in the years that followed. I’ll examine these tradeoffs more precisely in the coming weeks. But for now, consider what is not considered: What did we give up when Idaho lawmakers, and its governor, 60 years ago, agreed to participate in Medicaid? For one, politicians elected generations ago chose for us — and not in any especially deliberative way — how we express compassion for the medically indigent. They decided centralized charity administered through a bureaucracy was better than what friends, neighbors, churches, and community organizations would devise. We’ve never looked back. Subsequent generations were never asked if they could do it better or should even try.

Some will argue the existing system’s centralization has provided coverage for people in need; coverage they’d otherwise be unable to afford. But coverage isn’t care. Moreover, the centralized system leaves many people behind. The mere assumption that Medicaid provides for those in need often discourages scrutiny of the fact that many people on Medicaid find its coverage inadequate.

This isn’t a question only of dollars and cents. It’s not just a function of how well we tend to the state budget or how the government hires employees to administer a program. It’s a question of the very essence of our humanity, our willingness to pause and see if we’re doing well by our neighbors. In accepting and administering this program for 60 years, largely without reflection, have we prioritized compassion, or simply outsourced it to a bureaucracy? 

The dual-sovereignty structure of American federalism exists precisely so states can chart their own course when federal programming does not serve their people well. Idaho has that authority. Yet the state’s political apparatus has simply never exercised it — or even seriously examined whether it should.