The Trump administration released its fiscal year 2019 budget today, and it doubles down on what the administration has already been doing to undermine Medicaid—including more than $300 billion in cuts to the program and a call to take health insurance from those who can’t find a job.
Last month, the administration began testing these policies at the state level. On January 11th, the Centers for Medicaid and Medicare Services (CMS) announced that states can now compel low-income people who rely on Medicaid to meet “work and community engagement requirements” in order to keep their health insurance. Within a day of making this announcement, CMS approved Kentucky’s plan to implement such requirements. The plan strips Medicaid coverage from most adults who fail to comply, including those who do not complete paperwork on time or report “changes in circumstances” quickly enough.
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All told, Gov. Matt Bevin’s office estimates that around 350,000 Kentucky residents will be subject to the new requirements and 95,000 will likely lose their Medicaid benefits. But once those people are booted from the program, Kentucky is giving them a chance to get it back: through “a financial or health literacy course.”
Of course, this is not the first time that Americans have been required to meet economic standards or pass a literacy test to exercise their rights. Discriminatorily applied literacy tests, known for their impossible difficulty, were administered by election officials who were given immense discretion over who to test, what to ask, and how to assess the answers when (mostly black) citizens attempted to vote. Similarly, extractive poll taxes disenfranchised poor black populations (and sometimes poor whites) from the end of the 19th century until the advent of the 24th Amendment (1964) and the Voting Rights Act (1965).
These methods were incredibly effective at preventing black people from voting. They led to dramatic drops in black voter registration in the South, and in the states that were the most egregious offenders—like Louisiana—black voter registration decreased by as much as 96 percent over an eight-year span.
Of course, the electoral arm of white supremacy in the postbellum era stretched well beyond such tools (and all the way to violent repression). Nevertheless, taxes and tests stand out as especially contemptible because they officially codified a logic of exclusion aimed at those presumed unworthy of American citizenship.
On the surface, Kentucky’s new Medicaid rules don’t look exactly like poll taxes or literacy tests. But there’s an equivalent logic of exclusion that holds across both domains: Those who are unworthy—either because of their race or due to their inability to access decent jobs—are ousted. Their political and social rights (like the right to vote and the right to be healthy) are sacrificed on an altar built by those with power.
Since social rights like health care are connected to political rights like voting, undermining one deteriorates the other. When Medicaid recipients are made to jump through hoops to prove that they are worthy of health care, they quickly figure out where they stand in the American social hierarchy. And once that’s clear, they have a diminished desire to participate in politics.
I know this because I spent years studying Medicaid and wrote a book about the politics surrounding it. I had in-depth conversations with people who use Medicaid; I observed Facebook groups filled with Medicaid beneficiaries who readily recounted their experiences; I examined thousands of responses to large national surveys; and I scoured administrative records that detailed the actions that people with Medicaid took when they had scuffles with the government. I got to know some of the people who will find themselves at the losing end of the new Medicaid regulations, and I discovered how Medicaid shapes their political choices.
Take Angie, for example. Michigan’s Medicaid program stripped her coverage for not completing paperwork that she never even received. After battling for several months with local bureaucrats, she finally got her benefits restored. But by then she knew who she was in the eyes of the government:
“It’s like you are uneducated and you just want to get these free services and somehow you are inferior to other people if you receive those benefits … Once they hear Medicaid its ‘oh, one of those people.’”
Alienated from the government, Angie stopped voting and trying to advocate for herself. “I don’t do politics,” she said. When we talked about why she wouldn’t appeal devastating benefit cuts, she explained that she was a “nobody” and that the “powers that be” would not bend very far for her.
Angie was hardly alone. Ahmad fought back tears when he told me about the bureaucratic hurdles he faced after losing a limb in Iraq. Again and again he had to re-certify his enrollment, refile paperwork and find new medication when the old ones were no longer covered by Medicaid. He was clear on what this implied about his social status. “They treat us like we are stupid animals; like we don’t know anything,” he says. “I feel like I’m nothing, because when you are in Medicaid, they do whatever. You have to be on their rules.”
Just as literacy tests were applied unfairly by the election officials who administered them, adding stipulations to Medicaid will create opportunities for racial inequity. Blacks and Latinos face more labor market discrimination, have a harder time finding quality child care, and—because of biases in the justice system— are more likely to have a criminal record. In the face of such barriers, work and health literacy requirements pose burdens that will fall disproportionately on people of color.
That brings us back to where we started. Both types of literacy testing are predicated on assumptions about who deserves access to fundamental social and political rights, like health care and voting. Both also reinforce racial and economic inequality, whether purposely or inadvertently. Most crucially, both lead to the erosion of democratic citizenship among Americans whose political power has long been systematically suppressed.