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Since the 2018 midterm election, Democratic socialists have been leading voices in the Democratic Party, a trend that was all the more evidenced by Bernie Sanders’ resounding primary victories in states like Nevada, Colorado, and among others California. If anything, these voices have successfully brought poverty and social justice to the forefront of the Party’s politics as issues like child poverty, wages, housing and education dominated the primary debates. This was especially the case in Iowa on 14 January as protests by the Poor People’s Campaign took place outside the debate venue. The organisation represents the interests of the poor with a name referencing a series of demonstrations for economic justice organized in 1968 under the leadership of Martin Luther King.

Yet, one topic seemed to be paradoxically overlooked in the Democratic campaign: the future of the federal program Medicaid, which provides healthcare coverage to low-income people and is currently under attack in states like Arkansas, Michigan and Indiana, including via litigation in the courts. While Bernie Sanders had proposed to include the program in his universal healthcare plan so as to offer coverage to all US residents, Joe Biden, a moderate Democrat, has argued that “Medicare-for-all” would raise taxes for the middle-class. As Biden proposes to build on Obamacare, it remains unclear whether healthcare to the poor would be protected from state-level restrictions under his administration.


Medicaid in the states

Created in 1965, Medicaid currently serves 73 million low-income people throughout the United States. Like most federal social policies, it is jointly funded by the federal government and the states, who have retained significant powers over the administration of the program over the years, from levels of funding to eligibility requirements. In 2009, as the Affordable Care Act – also known as Obamacare – sought to expand Medicaid by providing greater federal funding and wider eligibility, many states refused to expand the program. Fourteen still do, mostly Southern states such as Texas, Missouri and Florida.

Instead, a number of states moved to restrict coverage and eligibility. Arizona, Kansas and Utah, among others, have notably tried to implement lifetime caps on Medicaid, although most of these attempts were rejected by the federal government. Lately, Republicans have increasingly favoured and implemented work requirements for Medicaid eligibility in places like Utah and Michigan, where they are currently being challenged in the courts by low-income people and healthcare advocates. Such conditions, which require unemployed recipients to work several hours per week in exchange for their healthcare benefits, are largely supported by the Trump administration, which earlier vowed to turn Medicaid over to the states through conversion into a block grant program. In February 2020, a federal appeals court struck down Arkansas’ Trump-approved work requirements, a case that may go to the Supreme Court if the Trump administration appeals the decision.


Putting the poor to work: a long history

The politics of Medicaid and work are contested and such conditionality of social benefits for the poor is not new. The implementation of work requirements as a technique to decrease public spending conjures up decades-old representations of the poor as unworthy of aid and unduly taking advantage of the welfare state. As sociologist Suzanne Mettler has observed, it seems that, in many ways, the present politics of Medicaid is following the path of welfare politics in the second half of the twentieth century.

One program through which we can track the development of work requirements in exchange for benefits is Aid to Families with Dependent Children (AFDC), a public assistance program created during the New Deal to enable needy mothers, then understood as white widows, to care for their children without having to take up employment. In the post-war years, the term “welfare” became synonymous with AFDC and took up racially-loaded, negative connotations as it came to be popularly considered to primarily serve unmarried, African American mothers. Between the 1960s and 1990s, “welfare” was the target of repeated attacks from local and national elected officials as AFDC recipients grew more numerous: 3.1 million people received AFDC in 1960, 4.3 million in 1965 and 10.8 million in 1974. Based on the prejudicial assumption that African American welfare recipients were merely lazy, work requirements were progressively implemented at the federal and state levels so as to decrease caseloads and budgets. In 1967, in the context of the urban riots that swept across America and the militancy of the welfare rights movement, which saw African American mothers fight for their economic rights, conservative Southern Democrats adopted the Work Incentive Program that forced all recipients to work in exchange for their check. Ensuing federal legislation in the early 1970s made work requirements mandatory in the states.

Starting in the 1970s, racialized images of “welfare queens” largely permeated the discourses of elected officials who sought to defend taxpayers’ rights and allowed for the passage of more punitive legislation. In a 1976 campaign speech, Ronald Reagan referred to the case of Linda Taylor, a mother from Chicago who had been charged with fraud, as a “welfare queen” who allegedly drove a Cadillac while claiming benefits under “80 names, 36 addresses, 12 Social Security cards.” Legislation during the Reagan presidency slashed AFDC budgets and strengthened work requirements. By the 1990s, anti-welfarism had also become the trademark of “Third-Way” Democrats. In his 1992 campaign, Bill Clinton famously promised to “end welfare as we know it”. In 1996, his administration replaced AFDC with Temporary Aid to Needy Families, a new and even stingier program that made work a pre-requisite for eligibility and capped benefits to five years.


Welfare politics and the Democratic campaign

In many ways, the road taken currently as regards the politics of Medicaid blatantly draws on the earlier politics of welfare. Restrictions to Medicaid in the states, notably in the form of work requirements backed by the Trump administration, might appear as a ripe topic for debate for Democrats in 2020, especially among progressives committed to social justice who stand in opposition to the Third Way of the 1990s.

Yet, the healthcare to the poor as such seems to have been overlooked in the primary. Medicaid was only scantly referred to during the debates, chiefly by Bernie Sanders. In Las Vegas, the Vermont Senator denounced having “to subsidize Walmart’s workers who are on Medicaid and food stamps because the wealthiest family in America pays starvation wages.” In South Carolina, former candidate Pete Buttigieg noted that life expectancy among black families was lower “in states where Medicaid was not expanded.”

In fact, it appears that debating governance of the current program may have been superseded by discussions of broader health care agendas. The most ambitious proposal on Medicaid in the Democratic field was indeed contained in Bernie Sanders’ Medicare-for-all program, also backed by Elizabeth Warren. An inclusive government health insurance system financed by federal taxes, the program would have subsumed both Medicare and Medicaid and eliminated eligibility requirements. As the federal government would have taken over the entire healthcare system, states would no longer be able to impose restrictive work requirements.

By contrast, presumptive nominee Joe Biden favours a “public option” that would enable low-income people to receive benefits even in the states that did not expand Medicaid – a system which does not specify whether the states that did expand the program would still be able to implement work requirements. Healthcare has been one of the most contested political issues of the last decade. With the coronavirus crisis raging throughout the United States, especially in large urban centres like New York City, the issue has taken on a new urgency likely to be at the core of the 2020 general election.



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