AMERICAN lawmakers are acutely afraid of rewarding the loafing poor. For that reason, Congress has set strict work requirements on federal food assistance and cash welfare. The Trump administration is now steadily doing the same for Medicaid, as America’s health-insurance programme for the poor is known. On January 11th the Centres of Medicare and Medicaid Services (CMS) issued a memo inviting states to apply for waivers that would include “work and community engagement requirements” on the theory that this would both improve health and help families “rise out of poverty and attain independence”. Ten states, all Republican-led, quickly took up the offer. Michigan, another Republican-controlled state, has contemplated a waiver of its own which would impose some of the strictest work requirements yet seen. The impetus is less financial than moral—an attempt to sort the deserving poor from the chaff.
The state proposals to reform Medicaid are fairly similar. Exempting the pregnant, disabled and others, all adults would have to work, volunteer or undergo job training to continue receiving benefits. Kentucky, the first to send a plan to CMS, set the minimum at 20 hours per week. Michigan had proposed 29 hours per week. After one warning, those who failed to meet the requirement would be locked out of coverage for a year.
The most controversial portion of Michigan’s plan would exempt counties with high unemployment rates, defined as 8.5% or higher, from the work requirements. Only 17 rural counties, with a total population that is 91% white, would have reached the threshold. The residents of struggling cities like Flint and Detroit, which have high unemployment rates and are disproportionately black, would not have qualified because surrounding counties are better-off. “Lot of folks that really need health care would lose it,” says Jim Ananich, a state senator from Flint.
The exempt counties are reliably Republican outposts, so currying favour with constituents is a likelier explanation than outright racial animus. “It was an honest effort to recognise that across the state there are variations in the ability to get jobs. There was no thought given to the R-word on this,” says Mike Shirkey, the Michigan state senator sponsoring the Medicaid legislation. Yet the effort has an unpleasant, and familiar, smell. Martin Gilens, a political scientist at Princeton University, has shown that antipathy towards welfare in the 1990s was driven by hostile attitudes toward blacks, who were thought of as lazy and undeserving.
A costly point
Though the unemployment provision was in the bill that passed the state Senate, the House could well strip it out before the governor, Rick Snyder, signs the bill, according to Mr Shirkey. To hurry Mr Snyder along, the state Senate also passed a budget which would suspend the salaries of top health officials if the Medicaid reforms are not speedy enough.
The plans seem likely to reduce the number of beneficiaries. Kentucky estimates that its rolls will shrink by 15%. Michigan’s legislative research staff suggest similar effects. But state bureaucracies will have to spend dizzying sums to create the infrastructure to monitor how much work people do. Kentucky will pay $374m to launch the plan—a higher cost than simply keeping the original one. Asked about the cost savings, Matt Bevin, the governor, said that he did not know, “nor do I care”. Saving money “wasn’t the intent” of the Michigan proposal either, says Mr Shirkey.
Americans on Medicaid are not merely poor. They are profoundly poor. Even after Obamacare’s expansion, a family of three would have to make less than $28,676 a year to qualify. The Brays, living in Ypsilanti, Michigan with their seven-year-old daughter, are one such family. Both are self-employed—Mr Bray as a metalworker and Mrs Bray as a weaver, primarily of baby wraps. The pending reform has left them worried. “I really have no idea how they are going to expect self-employed people to validate their hours. Are we exempt or are we excluded from Medicaid?” says Mrs Bray. “It would either be a lot of paperwork, or I would lose health care.”