It is the case that the GOP has been demonizing the word “entitlement” for decades, trying to cast moral aspersions on citizens who access public services.
However, the word has an particular meaning in federal and state appropriating and budgeting. Most notably in the Social Security Act, entitlements were created which attach to the beneficiary of the services. This distinguishes the govt responsibility to pay from “discretionary” programs. The entitlement means that when a qualified beneficiary accesses a service, the fed and state govt’s balance sheets are encumbered and they have the responsibility to pay. For example, if a qualified Medicare beneficiary gets a covered service from a participating hospital, there is an obligation to pay, whether or not the Congress has appropriated money for the program.
In budgeting, authorization means that Congress has passed a law that has certain rules about what money can be spent on (say the Defense Authorization Bill); authorizing legislation usually has dollar amounts in their language which means nothing. Authorization is drafted and worked on by the substantive committees, such as defense, foreign affairs, etc.
Appropriation means that the Congress has given the admin the power to spend money out of the federal treasury. Appropriations bills are drafted and worked on by the budget and appropriations committees and reported out to the House and the Senate. Most appropriations are for discretionary programs where the Congress sets a limit on what can be spent in a fiscal year and indicates what it can be spent for. If a contractor is say, building a weapons system, the DOD is given annual amounts that it can spend. Technically, if the weapons system is not finished, there is no responsibility to pay the following year.
Over in the Social Security Act (of which Medicare and Medicaid are Titles) there is a different system. Here, the Congress has determined the conditions under which individual citizens can qualify to seek services or payments. These “entitlements” track with the individual citizen. In the Social Security Act, there are also 2 large Trust Funds (Social Security and Medicare) into which payroll taxation is accumulated. However, the conditions in which there is an entitlement to a service or payment are independent of whether the Trust Fund has enough money. This makes these programs “uncontrollable” in the sense that the only control is to change the eligibility and coverage of the program. They are big enough that this makes budgeting difficult and makes any statement about federal spending subject to whether the Appropriators have correctly judged how many people will retire or go to a hospital to get care. Atop this, there are actual appropriations bills for entitilement programs that allow the govt to spend and they have actual limits, but the responsibility to pay is not limited by the amount appropriated.
The most particularly hard to manage entitlement program is Medicaid since it is a federal/state program and does not have a Trust Fund. Part of its complexity is that States cannot run deficits, but, as a condition of their State Plans, have promised to accept the responsibility to pay for any qualified beneficiary accessing a covered service from a participating provider. The typical way that this is handled is to cut payment rates or delay payment if the State legislature has not appropriated enough money.
The GOP has been trying to make Medicaid a block grant forever. One of the States (I think Tennessee) is trying to convert its program to a block grant as a “demonstration” program. It is being challenged in the courts and will probably fall over the part of the provision that holds that demonstration programs are to show better ways of delivering services, but cannot change the entitlement to the care (by those qualified). Medicaid State Plans have minimums that they have to cover and there are federal floors re eligibility. There has also been an attempt to put work requirements into place and they are being thrown out by the courts since Medicaid eligibility is a function of income and family configuration.
For those of us who want all Americans to have decent access to services and payments, we should be happy that these programs are entitlements. We should resist GOP efforts to demonize.