Donald Trump ran for president on a narrative of economic populism, pitched mainly to working class whites, that was supposed to contrast sharply with decades of conventional GOP economic orthodoxy, with its emphasis on the idea that the way to help economically struggling Americans is with tax cuts for job creators and liberation from dependence on the safety net.
Once in office, Trump has fully embraced policies that rest firmly on that same economic orthodoxy — policies that are ostensibly designed to help economically struggling Americans with tax cuts for job creators and liberation from dependence on the safety net.
Here’s the latest example of this: The Trump administration has just announced it will allow states to impose work and other requirements on recipients of Medicaid. This is a big change. After the failure to repeal the Affordable Care Act, this is meant to begin rewriting the social contract at the core of government-sponsored medical insurance, and especially the ACA’s Medicaid expansion, shifting away from the notion that health coverage should be available to those who cannot afford it as a matter of societal right. As such, it may have a negative impact on untold numbers of Trump voters.
The core ideological idea behind the change is that Medicaid can be improved by using it to incentivize (i.e., require) able-bodied adults to work, or seek job training or education, or enter into other forms of “community engagement” to collect benefits. The federal government will now allow states to “test” such policies, to improve the “well being” or foster the “independence” of Medicaid enrollees. The Obama administration had refused to grant such requests by states, on the grounds that such requirements don’t “further the objectives” of Medicaid. The Trump administration thinks these requirements will further those objectives.
In the background of this argument is a deeper dispute. Some conservatives have attacked the ACA’s Medicaid expansion because it extends Medicaid coverage to many more poor “able bodied adults,” which they oppose either because this risks trapping them in dependency or because they think redistributing to those who can support themselves is inherently wrong. But liberals argue not just that basic medical coverage funded by taxation should be available as a right, including to people who are able to work and/or do work but cannot afford coverage, but also that it is liberating to poor people and makes it easier for them to work.
Buttressing the liberal argument, a recent Kaiser Family Foundation analysis found that of the nearly 25 million non-elderly Medicaid recipients, a majority are already working, meaning they qualify for Medicaid (and thus can’t afford insurance) even though they are employed, which allows them to work these jobs and still get coverage. Meanwhile, of those who are not employed, most report serious health and other impediments to working, meaning the obstacle isn’t dependency or a lack of motivation.
And so, in states that adopt these requirements, they may end up pushing those who are already working (and thus don’t want to meet the requirements) out of coverage, or they may end up pushing out of coverage those who already cannot work (and would thus struggle to meet the requirements).
Such requirements are likely to be imposed in states carried by Trump. The Post reports that 10 states are already trying to get permission to impose them, almost all of them red states. This, among other things, leads Harold Pollack, a health policy expert at the University of Chicago, to conclude that “Medicaid work requirements may hit Trump country hardest.”
“They could hit under-employed early-retirees who now find themselves reliant on Medicaid,” Pollack told me Thursday. “They could hit surprising numbers of people with disabilities — including addiction to opioids — who are covered under the ACA Medicaid expansion but can’t fill the requirements. They could hit hospitals in low-income rural areas that provide services to people who have lost Medicaid and can’t pay.”
Beyond the substantive debate over work requirements, this is not the story Trump told during the campaign. He sent a strong message that he was not a Paul Ryanist Republican on economic matters. He vowed to go after Wall Streeters who had engorged themselves off the rigged the economy. He vowed to protect the safety net, generally holding up the Orthodox Ryanist vision of it (which treats it as a “hammock” of “dependency”) as a foil. But now Trump has signed a tax bill that lavishes enormous benefits on financial elites and further rigs the tax code in ways they’re well positioned to exploit. He has gone all in with Orthodox Ryanism on the safety net, moving to roll back health coverage for millions (but failing). Now his administration is shaping policy around the Ryanist idea that the safety net is a dependency trap.
But, as Pollack points out to me, this demonstrates again that elections have consequences. The Trump administration is simply acquiescing to the demands of many Republican legislators across the country who are where they are because Democrats lost so much ground on the state level during the Obama years. “If we liberals don’t like work requirements, we need to get out there and actually win more elections,” Pollack says. Including in Trump country, as Thursday’s announcement underscores.