Poverty was all Lucy* had ever known. Early in her adult life, a mixture of desperation and patriotism led her to join the military. When she left her three children and headed to the frontlines of the “war on terror,” it was with the goal of providing a better life for them. There, Lucy gained skills that she hoped would enable her to earn a steady income, but she returned home to find that good jobs were scarce, especially for an African-American woman. As a result, Lucy accepted a part-time position as a cashier making $7.50 an hour. Her pay was not enough to make ends meet while supporting her children and caring for her elderly parents. Most distressingly, she could not afford health insurance, and even though her income fell below the poverty line, she was ineligible for Medicaid.
If Lucy lived in New York, where I was born and now live, she would have access to health care. But her home state of Georgia had the second-highest percentage of uninsured residents in the country and did not plan to utilize the Medicaid expansion subsidized through the Affordable Care Act. As the summer of 2012 came to an end, she had difficulty getting her children signed up for Georgia’s Medicaid program and could not afford to pay for the immunizations required to enroll them in school. Adding to this, Tiffany, her eleven-year-old daughter, had a severe case of asthma, so Lucy placed a moratorium on all outdoor play. When Tiffany protested, Lucy regretfully explained, “You can’t go outside and play now, I don’t have Medicaid… if something happens and you have an asthma attack, I don’t have the medicine to give you.”
Lucy’s narrative is not unique. I have interviewed many Medicaid beneficiaries who recounted similar struggles. The details differ but the theme is clear: for Americans who live in poverty, the public benefits available to them are contingent on where they live. Your state legislature determines whether your kids are left without braces, whether your third degree burns remain untreated, and whether your illnesses go undiagnosed.
This is not an accident. Rather, it is a direct product of our nation’s enduring commitment to federalism, a political system that divides power between the national government and subnational entities, giving states and localities significant discretion in shaping policy outcomes.
Consider the perspective of Speaker of the House Paul Ryan, whose silver-bullet solution to poverty is to “consolidate many of our federal poverty programs into flexible programs that go to our states to customize a welfare benefit for a person’s particular need.” Ryan’s ideas are widely shared. When conservatives recently gathered in South Carolina for a forum on poverty, their devotion to increasing the power of states was on high display. Common proposals involved converting Medicaid and SNAP into block grants, which give states broad flexibility to design and distribute public assistance programs—with little oversight. While conservatives reason that states could leverage this increased control to tailor anti-poverty policies to the needs of local populations, evidence suggests that such grants are harbingers of retrenchment: dramatically decreasing the resources directed to the most needy and removing any guarantee of aid.
In addition to promoting harmful budget cuts, block grants are simply unnecessary. States already have plenty of power over anti-poverty programs like TANF and Medicaid and, in some cases, an infamous proclivity for misusing it. States decide whether to offer certain medical services to the needy, like dental benefits and eye care. They set income caps for various forms of assistance. They choose how often beneficiaries need to re-enroll, how burdensome application processes will be, and much, much more.
What it means to be poor in Mississippi is very different in Maryland and starkly divergent from Maine. It is clear that, in the realm of poverty, states already dominate. And to what end? There is scant evidence that local control is an effective way of alleviating poverty. Instead, research demonstrates that it undermines racial and gender equality and exacerbates geographic disparities. In short, unbridled federalism takes us down an inegalatarian path.
But perhaps most troubling, such a road leads us away from a robust democracy.
For Lucy, the first word that came to mind when I asked her about politics was, “dirty.” After nearly an hour of discussing how sharply Medicaid differed across states, I asked her if she thought this was at all connected to the political system. She deftly declared:
“Instead of sitting up high and looking low, they sit high and look higher… I don’t even know who my politician is, I don’t know who half of who the higher-ups are because they don’t branch out, they don’t make themselves known. …To us, sitting down here looking at those up there, it’s like our voice, what is my little voice going to do?”
Political scientists have already shown that citizens’ experiences with the government have profound consequences for democracy. When states use their considerable authority to retract services or limit benefits, struggling Americans’ views of government are negatively affected, and they exhibit decreased willingness to engage in politics. In particular, when individuals who bear the brunt of harmful state policy decisions become aware of geographic inequities in assistance, they can begin to view the political system as arbitrary and unfair. For instance, after John, a chronically ill Medicaid beneficiary from Michigan, discovered that he could not move with his family to Arizona without risking the loss of life sustaining treatment, he began to see the government as an oppressive force in his life. Similarly, when Terrie’s grandmother visited from out-of-town and Medicaid refused to cover her prescriptions, Terrie wondered, “what kind of government” would punish you for crossing state lines? People like John, Terrie and Lucy do not experience social policy in a vacuum, but rather within a multi-tiered political system.
Devolving power to states serves many purposes and can sometimes be quite beneficial. But when it comes to anti-poverty policy, federalism has too often been used to harm those who are most vulnerable. Policymakers must take care to limit those harms and ensure that they do not imperil democratic citizenship.
State residence is a basic condition of birth and circumstance. Why, then, should it determine access to potentially vital resources like food or medical care? We cannot fully grapple with economic and political inequality unless we ask this question and press for better answers. There is a sordid history that links race, class and federalism in the United States. Learning from our past means listening to people like Lucy and challenging both the retrenchment and the ballooning geographic inequities that accompany block grants. It also means interrogating any policy that empowers subnational governments while disempowering low-income Americans.
*Name has been changed to protect confidentiality