Medicaid Is Not Welfare
Lessons from Princeton Model Congress
This week, there was a New York Times op-ed about Republican efforts to make Medicaid recipients work for their health insurance. The article was so unintentionally evocative of Washington in the 1990s that reading it transported me back to my own time in DC in those days, as a teenager in a gigantic—yet maybe fashionable by the standards of the time?—three-button sportscoat, spending a few joyous days each year playacting as a member of the United States Congress.
Going to Washington, DC for Princeton Model Congress combined the thrill of pretending to be an adult legislator with the adventure of going on a trip without your parents. During the day, you’d write a bill and debate its merits with a committee of teenagers you’d never see again. At night, everyone from your school would go out to dinner together and you'd see your teachers in the wild, ordering appetizers and wearing jeans. Then you’d go back to the hotel, where you’d share a room with one good friend and two kids you’d rarely interacted with outside school, one of whom you would find out slept in a full sweatsuit.
A lot of kids at my high school were interested in politics, so we always had a big contingent at PMC. My senior year, one of my classmates was even elected “President of the United States.” He gave a great speech the first night and he also had cool campaign buttons, and the kid from Parsippany, New Jersey, didn’t, so he won. I had the privilege of serving in his cabinet as the Secretary of Housing and Urban Development, like a young Andrew Cuomo.
Every year at Princeton Model Congress, I introduced a version of the same bill: a repeal of the Personal Responsibility and Work Opportunity Reconciliation Act, more commonly known as Bill Clinton’s 1996 welfare reform. Teenagers in the Nineties could be skaters or goths or jocks or wannabe rappers—my fledgling adolescent identity was “unreconstructed New Deal liberal.”
My many happy memories of Princeton Model Congress came flooding back this week when I read “Trump Leadership: If You Want Welfare and Can Work, You Must” in the Times. This was the line in particular that hooked me.
In 1996, President Bill Clinton and the speaker of the House, Newt Gingrich, joined forces to enact bipartisan welfare reform with a work requirement at the heart of it.
There it was, the very legislation I’d so passionately opposed all those years ago. But this op-ed, authored by four members of the Trump administration, isn’t really about welfare—it’s about Medicaid. Faced with the uncomfortable fact that most Americans really like—and have benefited from—Medicaid expansion, Republicans who want to cut Medicaid without facing the consequences of being “morally wrong and politically suicidal” are trying out a new approach: rebranding Medicaid as welfare.
To that end, the authors trot out the same tired canards that America’s favorite codependent boomer creeps, Gingrich and Clinton, relied on to pass welfare reform thirty years ago—the shrill dog-whistles of “dependency” and “dignity,” and how welfare increases the former while diminishing the latter. Here’s what the op-ed says:
Millions of able-bodied adults have been added to the rolls in the past decade, primarily as a result of Medicaid expansion. Many of these recipients are working-age individuals without children who might remain on welfare for years. Some of them do not work at all or they work inconsistently throughout the year.
I’m willing to cut the piece’s authors, which include Robert Kennedy, Jr. and TV’s Dr. Oz, a little slack. Kennedy and Oz are responsible for Medicaid now but they’re also both very rich and very new to government. So maybe they don’t know what Medicaid actually is or does? Here’s a quick primer for their benefit.
Medicaid does not provide cash benefits. You can’t pay your rent with Medicaid or buy groceries with Medicaid or even use Medicaid to pay for the raspberry ketones Dr. Oz has promoted as “the No. 1 miracle in a bottle to burn your fat.” Medicaid is health insurance. It pays for doctor’s visits and hospital stays and prescription medicine, which can be delicious but is not food.
I can’t just go back to my notes from Princeton Model Congress—not because I don’t have them anymore, obviously I’d never throw those out, but because they’re currently in a box in a storage unit we rented after the Los Angeles wildfires. So I’ll just summarize my old speech and say that welfare reform was premised on a lot of lies. Fortunately for the reformers, they were lies that people wanted to believe.
A hypothetical statement like “able-bodied adults should have to work to receive cash benefits from the government” is irresistible to many taxpayers, even if it reflects a reality that exists mainly on a pollster’s questionnaire. The prime beneficiaries of public assistance were always children, which was a major inconvenience for the boosters of welfare reform. The lived experience of poor and hungry kids was much more sympathetic than the imagined prevalence of adults grifting the government.
That’s why the reformers were so keen to rename the federal government’s central welfare program: Aid for Families with Dependent Children became Temporary Assistance for Needy Families. Welfare reformers have long used metaphors to obscure the truth of what they’re advocating: to them, welfare was not about what it did, like feeding kids or keeping families from becoming unhoused, it was about what it represented. Welfare was a cycle to be broken, “a lifelong trap of dependency,” as TV’S Dr. Oz et al. call it. “Temporary Assistance” is code for only tolerating people being poor for a few years—anything beyond that would just be tacky.
Deceptive language has always been a favored tactic for welfare reformers, but the same tropes don’t work quite as well for Medicaid expansion. The authors of the op-ed generously concede that “America’s welfare programs were created with a noble purpose,” to help “the truly needy.” It’s very cool of them to notice all that, but the goal of Medicaid expansion, as part of the Affordable Care Act, was not to help only those most in need—it was to increase access to affordable healthcare. It’s right there in the name of the law!
The op-ed’s authors warn that, without work requirements, “welfare is no longer a lifeline to self-sufficiency.” When applied to Medicaid, the analogy falls flat: health insurance isn’t a lifeline to self-sufficiency—it’s a lifeline, period.
One can perhaps argue that, in theory, receiving cash from the government creates an incentive not to work. It makes no sense at all, however, to claim that access to basic health insurance has the same negative effect. In California, a single “able-bodied adult” has to earn less than $22,000 a year to qualify for Medicaid. Even the most gifted stereotypist among the welfare reformers would struggle to imagine the adult who can afford not to work simply because they have Medicaid. It’s telling that the Republicans pushing for Medicaid work requirements aren’t even trying.
There’s no “welfare queen” for Medicaid—and the Medicaid slashers know it. Trying to pass off Medicaid as cash welfare is a desperate move, but they don’t have much else to work with. Georgia is the only state that imposes work requirements on Medicaid recipients, and here’s how it’s going, according to the Washington Post.
Just 12,000 of the nearly 250,000 newly eligible Georgians ultimately received Medicaid, the public health insurance program for the poor and disabled, well short of the state’s initial 50,000 goal. Administrative costs far outpaced spending on medical care.
These desperate attempts to de-insure millions of Americans point to two inescapable facts about today’s Republican Party.
First, their never-ending pursuit to dismantle the Affordable Care Act reveals an enduring obsession with Barack Obama—elected President seventeen years ago!—that puts any perceived liberal fixation with Donald Trump to shame. I mostly forgot about Trump when Joe Biden was President, taking my cue from President Biden himself, who apparently mostly forgot about everything when he was President.
Second, there’s a lot about the current administration that may be new and shocking, but huge parts of their policy playbook are old and stale. They’re still using the same talking points which I, in a crackling voice in a Marriott conference room in a previous century, rebutted so successfully that I won an honorable-mention certificate from the marginally older undergrads who ran Princeton Model Congress. It wasn’t as good as a gavel but it went on my college applications anyway.
They language even in their Times piece, bringing back that term “the rolls” (“Millions of able-bodied adults have been added to the rolls”).