Trump's sneak attack on the poor

How the Trump administration is using Medicaid to wage war on poor people

President Donald Trump at a meeting on health care.
(Image credit: Mark Wilson/Getty Images)

Do you have a lazy cousin you just can't stand? Always leeching off other people or working some kind of scam, no visible source of income, thinks he can just take advantage of the system while everybody else has to work for a living? Does he really drive you nuts?

Well the Trump administration and Republicans in Congress couldn't be happier about how mad your cousin makes you. They want to nurture that resentment and turn it into public policy, so they can dismantle our system of social supports.

It won't be easy, particularly if they try a frontal assault. That's what they found out when they tried to eviscerate Medicaid as part of repealing the Affordable Care Act. They figured folks wouldn't mind — after all, Medicaid is a program for poor people. So they were completely blindsided by the backlash to their plan. It turned out that Americans love Medicaid — according to Kaiser Family Foundation polls, 74 percent of Americans have a favorable opinion of the program, and 87 percent want its funding increased or kept the same.

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And because the program was expanded as part of the ACA, it isn't just for poor people anymore; as of last fall over 74 million Americans were on Medicaid or CHIP (the affiliated program for low-income children).

So Republicans want to find less direct ways to chip away at Medicaid, which is why the Trump administration just announced that they'll allow states to impose work requirements on Medicaid recipients. Multiple Republican-run states are eager to take advantage of the change, and 10 states have already applied. This move isn't practically necessary or even justified; the real purpose is to get people associating Medicaid with that lazy cousin of yours.

The truth is that America isn't full of people who think they don't have to work once they get that sweet health coverage. According to KFF, among adults on Medicaid, "nearly 8 in 10 live in working families, and a majority are working themselves." The problem for many is that their employers don't offer health coverage and they don't make enough to afford it on their their own. "Among the adult Medicaid enrollees who were not working, most report major impediments to their ability to work including illness or disability or care-giving responsibilities."

So a work requirement isn't a solution to a real problem, it's a way of putting bureaucratic hurdles in front of people to make it harder for them to get health coverage. Which gets to a fundamental divide between liberals and conservatives: When someone gets kicked off Medicaid, or finds the process of applying too daunting and doesn't bother jumping through all the hoops even though they're eligible, liberals consider that a tragedy.

Republicans, in contrast, consider it a success. "People moving off of Medicaid is a good outcome because we hope that means they don't need the program anymore," says Seema Verma, the Mike Pence ally whom Trump put in charge of Medicare and Medicaid. They "hope" that's what it means, but it could also mean that they've lost their eligibility because they couldn't jump through the hoops their state just put in front of them.

Which is one more reason why Democrats' long-term goal ought to be to nationalize Medicaid. The fact that it's jointly run and funded by the federal government and the states has led to all kinds of distortions, most of which punish those unfortunate enough to live under Republican rule. In red states, eligibility requirements tend to be much more strict, so that in some places if you make enough money to avoid living in a van down by the river, the state probably considers you too rich for Medicaid. In Texas, for instance, parents who make more than 18 percent of the poverty level — or $4,428 a year for a family of four — are too wealthy to qualify. Childless adults are banned from getting Medicaid entirely there and in 16 other states entirely or partially controlled by Republicans. And it's just those states that are going to be eager to impose work requirements.

We could solve that problem by cutting states out of the policymaking (and relieving them of the financial burden) and just making it an entirely federal program. But Republicans will resist that mightily — their priority is to cut it and discredit it in any way they can, and state control provides an avenue to do that.

If Republicans are going to undermine support for Medicaid, they're going to need people to think of the program's recipients as undeserving, slothful moochers who are living off "welfare" while refusing to work. Just in the last few weeks, they've begun taking that stigmatized term, which has always referred to cash payments, and applying it instead to any government benefit that Republicans are looking to cut. You can expect to hear that a lot soon, along with the false idea that it's vital we impose work requirements to keep your cousin from getting something he doesn't deserve.

It's important to point people's resentment downward, lest folks look around and realize that the GOP wants to cut social programs right after it gave corporations and the wealthy a gigantic tax cut. That wouldn't do at all.

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