ABSTRACT
This chapter explains the importance of an "American exceptionalism" noted by Alexis de Tocqueville and others as distinguishing the country from European nations: the absence of an aristocracy, an established church, or strong institutions of central government, and yet the presence of a developed and dynamic civil society. The Social Security Act of 1935 was of historic significance for several reasons. It established the welfare state in America, by moving on from the alphabetic emergency agencies of the New Deal and giving to the successor agencies a firm institutional foundation on which future programs would build, such as disability insurance, supplementary security income, and Medicare and Medicaid. Medicaid is in its unique way, shaped by weaknesses of American government and our cultural attitudes toward the poor, women, and racial minorities. Medicaid is a state-based and administered program, so that federalism is itself one of the most important checks on power and a source of pressures for decentralization or devolution.
