The Politics of Medicaid

The latest on Trump’s Medicaid work reporting requirements, with Dr. Jamila Michener; PLUS: how Michigan’s GOP is subverting democracy to stop a minimum wage hike, and other news of the week ICYMI.

This week on Off-Kilter, while Medicaid expansion continues to gain traction in red, blue, and purple states alike, in what feels like a totally different universe, the Trump administration’s Medicaid work reporting requirements — which are really just cuts in disguise — continue to spread like wildfire. Just before Thanksgiving, we learned that the number of people who’ve lost Medicaid in Arkansas has now officially topped 12,000 in just the past few months since the state’s work reporting requirements took effect. That was apparently all the Trump administration needed to hear to decide to double down on the damaging policy, giving Kentucky a second chance to implement its own work reporting requirements that had previously been struck down by a federal court. Rebecca talks with Dr. Jamila Michener, professor at Cornell and author of Fragmented Democracy: Medicaid, Federalism, and Unequal Politics, to dig into the good, the bad, and the ugly on the Medicaid front — and how work reporting requirements may represent the newest form of voter suppression.

But first, Michigan Republicans (and the national restaurant lobby) are so desperate to prevent a minimum wage increase in their state, they decided to pass it into law — so they can repeal it; a new report finds majority-black communities are losing billions due to racial bias in the housing market; Trump denies his own admin’s climate report; Melania’s White House holiday décor or The Shining: who wore it better? and other news of the week, as Jeremy Slevin returns with the latest edition of ICYMI (and a never-ending packet of peanut butter crackers).

This week’s guests:

• Dr. Jamila Michener, professor at Cornell and author, Fragmented Democracy: Medicaid, Federalism, and Unequal Politics
• Jeremy Slevin, director of antipoverty advocacy at the Center for American Progress (and faithful sidekick)

For more on this week’s topics:

• Read more from Jamila Michener on the politics of Medicaid and the history of race and racism in the U.S. healthcare system in her book Fragmented Democracy and in this essay for Vox
• Catch up on the rising toll of Arkansans who’ve lost Medicaid due to the state’s harsh work reporting requirements and the Trump admin’s reapproval of Kentucky’s damaging policy (previously struck down by a federal court) via the Center on Budget and Policy Priorities
• Read Washington Post columnist Catherine Rampell: “Are Medicaid Work Requirements Inherently, Irredeemably Flawed?” (tl;dr? the short answer is yes).
• Get up to speed on how Michigan Republicans are subverting democracy to steal a minimum wage hike and paid sick leave from the state’s workers

What we’re reading this week:

• Greg Kaufmann for The Nation: “The New Democratic House Needs an Anti-Poverty Agenda”
• s.e. smith for TalkPoverty: “Crowdfunding is a symptom of America’s sick health care system”
• Pat Garofalo for TalkPoverty: “Black Friday isn’t the only time workers face unfair schedules”
• And here’s the epic McSweeney’s piece proposing soundtracks for Melania’s holiday décor (you’re welcome)

This week’s transcript:

REBECCA VALLAS (HOST): Welcome to Off Kilter, the show about poverty, inequality and everything they intersect with, powered by the Center for American Progress Action Fund. I’m Rebecca Vallas. This week on Off Kilter, Medicaid expansion continues to gain traction in red, blue, and purple states alike, while in what feels like a totally different universe, the Trump administration’s Medicaid work reporting requirements — which are really just Medicaid cuts in disguise — continue to spread like wildfire. Just before Thanksgiving, we learned that the number of people who’ve lost Medicaid in Arkansas has now officially topped 12,000 in just the past few months since the state’s work reporting requirements took effect, which was apparently all the Trump administration needed to hear to decide to double down on the damaging policy, giving Kentucky a second chance to implement its own work reporting requirements that had previously been struck down by a federal court. So I talk with Dr. Jamila Michener, a professor at Cornell and author of “Fragmented Democracy: Medicaid, Federalism and Unequal Politics” to dive into the good, the bad and the ugly on the Medicaid front and how work reporting requirements may represent the newest yet hidden form of voter suppression.

But first Jeremy Slevin is back, it’s been a while but ‘In Case You Missed It’ is back.

JEREMY SLEVIN: We’re back!

VALLAS: Jeremy thanks for coming in.

SLEVIN: Of course.

VALLAS: And you’re putting like a cracker in your mouth.

SLEVIN: Yeah.

VALLAS: I think it’s a peanut butter cracker.

SLEVIN: It is. It’s dinner time.

VALLAS: This is just going to go great for radio.

[LAUGHTER]

SLEVIN: Well that was the plan you know, this is a late night edition of ‘In Case You Missed It’ so I gotta have my dinner which is peanut butter toasties.

VALLAS: I’m very pro-eating, I think that people should eat. I’m often bad at doing that at the office and I forget to eat. But I have to say you are blazing new trails by making peanut butter crackers, which are maybe the worst thing you could possibly put in your mouth when you then plan to say things that are going to be intelligible, right?

SLEVIN: We’re definitely not in the radio studio, by the way where eating is not allowed, just to clarify, we’re not there, we’re not there.

VALLAS: To anyone at the Center for American Progress Action Fund —

SLEVIN: We’re in a totally different place.

VALLAS: Who cares, we’re not taping at the — nope, nope. Anyway and Jeremy clean that up later. So onto much more important things that are incredibly timely and getting all kinds of really important attention on the internets and they have a ton to do with poverty.

SLEVIN: Yeah.

[LAUGHTER]

VALLAS: Actually it has nothing to do with poverty, we have to start with Melania’s Christmas decorations at the White House.

SLEVIN: Yeah.

VALLAS: I am sorry but what is going on?

SLEVIN: I think you were the last person on earth who had not seen them before I made you look at all the memes before.

VALLAS: Yeah.

SLEVIN: But in case there are any other people on earth, this year’s White House Christmas decorations are somehow all red trees. I think they’re covered in cranberries or something but it looks like a creepy blood red Christmas massacre.

VALLAS: I mean it looks like ‘The Shining’ holiday edition.

SLEVIN: Yes.

VALLAS: That’s actually what it looks like the tidal wave of blood that’s coming down the hall in the hotel in the movie. That’s actually what this looks like. What was going on?

SLEVIN: I don’t know. If folks remember last year it was barren branches with stark white lighting. So there’s some disconnect between normal people and –

[LAUGHTER]

VALLAS: That’s one way to put it, or she’s trying to send us a message. I feel like wasn’t there a whole theory about she blinks twice when she’s saying please rescue me from this man.

SLEVIN: There’s gotta be a message.

VALLAS: Right? I’m sorry but nobody would, year one, barren trees and year two blood red trees on accident.

SLEVIN: Yeah I don’t know how they’re going to top it next year.

VALLAS: Well, I mean —

SLEVIN: Can I read briefly so, McSweeney’s —

VALLAS: I was going to ask you to do this.

SLEVIN: Did a sound track to Melania’s Christmas decorations so some of the most choice answers or what they submitted are heavy breathing, the soft laughter of child who lived 200 years ago, “Silent Night” slowed down in the key of a-minor vocals by Lana Del Rey.

VALLAS: Oh my God.

SLEVIN: The clicking of the chains of Jacob Marley forged in life, oh Jacob Marley, ok.

VALLAS: Yeah Jeremy, you don’t seem to be familiar with the cannon.

SLEVIN: Oh, “A Christmas Carol”.

VALLAS: Yes.

SLEVIN: Got it.

VALLAS: That’s a classic.

SLEVIN: That was a right click search Google for.

[LAUGHTER]

VALLAS: Keep going, sorry.

SLEVIN: Oh ok I’ll go through all of them. We gotta go back.

VALLAS: Oh they get better and better.

SLEVIN: Yup, a skipping, scratching recording of ‘Santa Claus is Coming to Town’ stuck on the lie “You better not cry.” A silence so deep and lonely you feel you will never escape it. White House aides nervously asking why is it so cold in here all the sudden?

VALLAS: That’s the most realistic one by the way, that’s really happening right now.

SLEVIN: The wailing of the olds ones as they awaken from their long slumber and a recording of Samuel Beckett’s death.

[SIGH]

VALLAS: Thank you McSweeney’s, that was necessary.

SLEVIN: Yes thank you Rebecca Turkewitz.

VALLAS: Oh my God, well with that as obviously the most important poverty and inequality related news of the week.

SLEVIN: Yeah, I mean inequality, you know.

VALLAS: Well yeah that’s true.

SLEVIN: Good thing we didn’t try to force it into our [INAUDIBLE] and just talked about it.

VALLAS: That’s something I would never do, Jeremy, jeez. So OK, so taking away from Melania just for a second and onto maybe more a little of a policy conversation.

SLEVIN: Yeah, a little more consequential this one.

VALLAS: Over into other parts of the White House, this has been an interesting week when it comes to climate change when it comes to Trump deciding he doesn’t like his own administration’s report. What’s going on there?

SLEVIN: So this is an annual climate report that the U.S. government puts out. It’s interagency, cuts across almost a dozen agencies. It is normally a big deal. It’s 1,500 pages long, it is the most damning report yet. It basically, I’m quoting, “climate is now changing faster than at any point in the history of modern civilization, primarily as a result of human activities.” It usually comes out in December. This year it came out the Friday after thanksgiving.

VALLAS: Oh funny, I feel like that’s one of the days everybody’s reading the news. The day you release something you want everyone to see.

SLEVIN: It’s a very popular news day, no one is out shopping, everyone is just on their laptop reading the news. Of course, that’s not true. None of the, 13 federal agencies were involve, virtually none of them even acknowledged it as opposed to years past where they all put out statements and releases and blogged about it.

VALLAS: So first they tried to bury it on Black Friday. But then what happened next?

SLEVIN: So then they didn’t acknowledge it. Then Trump was asked about it and he basically said he didn’t think it was true. He denied the accuracy of the report, his EPA director said he had questions about the assumptions of the report, essentially the assumptions being that the climate is changing, which not really an assumption so much as a fact. So that’s where we are.

VALLAS: So where do we go from here? What are the actual implications? I feel like it’s not an unusual day when Trump says things that are not true or backtracks or tries to hide facts, including even ones that have come from his own administration. Clearly he’s very focused on raking right now, his big environmental —

SLEVIN: That’s the big climate solution.

VALLAS: That really is and I’m waiting for the news to break that Rick Santorum has been selected as his secretary of raking, given that he’s actually back him and saying no this is a serious policy idea, which is amazing on many, many, levels.

SLEVIN: It’s almost like if you put a coal lobbyist in charge of the EPA — oh wait.

VALLAS: I feel like we’ve lost the fox guarding the hen house as a metaphor to use anymore because we’ve used it so many times for this administration and the choices that they’ve made. Where do things actually go from here? What does this mean?

SLEVIN: Great question, so the follow-up to the famous Paris Climate Accords, it’s happening next week in Poland. All the countries in the world including the US who’s no longer part of the Paris Climate Accord are meeting. And separate from the administration’s report the UN just put out a report that basically no one is meeting their goals for the Paris Climate Accords. So in perhaps the most pivotal moment for the future of human civilization —

VALLAS: Not to put high stakes on anything.

SLEVIN: Not hyperbole, you have the most powerful and largest historical emitter denying climate change and denying any solutions designed to mitigate or reach those targets, which sets an example for other countries who don’t have as much clout.

VALLAS: So just to move on from that because there’s just so much there and we’re overdue for a segment on climate and the impact of climate change, the disproportionate impact of climate change on low-income populations, on communities of color, that is something we will queue up for an episode soon to come. But shifting gears, there also was a study that came out this week from Brookings that had really stark findings about Black homeownership. What did we hear out of Brookings there?

SLEVIN: Yeah and that’s just this week. They did a comprensive study of homeownership in the U.S. and they found that Black homes are undervalued by an average of $48,000 and that totals to over $150 billion in cumulative losses. And that’s controlling for the communities and the neighborhoods, it is above and beyond they are undervalued.

VALLAS: So what do we know about what’s driving this? Is this that there is active under, is there actual discrimination in how homes are being valued, is that what’s going on?

SLEVIN: That’s there conclusion because they are controlling for the different neighborhoods people are in. so it’s not just these communities have cheaper homes for example because of the housing market. They say they are losing out in the housing market stemming from racial bias by $156 billion. Additionally homes and neighborhoods where the share of the population is 50% Black are valued at about half of the price of homes in neighborhoods with no Black residents.

VALLAS: So huge, huge numbers being put to the question of what is the cost of racial bias? So we’re starting to get some answers there in the housing context and really, really stark. And of course hard to talk about this without connecting some of the literature telling us that middle income Black families for example live in neighborhoods with lower incomes than the typical low income white family. So you’ve actually got all these kinds of housing disparities that this is fitting into but on top of all of that you’re also actually seeing money literally stolen out of the pockets of Black families in the form of undervaluing of their homes.

SLEVIN: Right, right and of course a lot of this is the legacy of red lining and discriminatory housing and we see the consequences in study after study that mobility, economic mobility was lower for Black families as a result.

VALLAS: So now the conversation that I wanted to leave some time for because often I get talking about your beard or your sweaters and then my god the clock has just run out! So notice, I didn’t bring up either.

SLEVIN: Well good thing I’m not wearing a sweater today because it’s 80 degrees in this room.

VALLAS: That was part of why I didn’t bring it up, if you were wearing a great sweater as you often do, I probably would have said something, the radio studio that we’re not taping in right now is really warm so I’m glad you’re not. So the thing I want to leave some space for because boy is it friggin’ bananas, what’s playing out right now in Michigan is the active subversion of democracy that we are watching play out, driven by Republicans in that state’s legislature and this all has to do with the minimum wage, the tipped minimum wage and paid sick leave. So what’s going on in Michigan?

SLEVIN: Yeah so we’ve talked about this a lot on the show in the context of DC where the council repealed a popularly passed ballot initiative to raise the tipped minimum but it’s almost more evil. What Republicans did even before the election is they basically, a minimum wage and paid leave both passed as ballot initiatives and passed laws affirming that so it would be easier to repeal because the Michigan constitution they thought they couldn’t repeal it outright if they didn’t pass it before. So now they’re at the point where they are actually repealing or technically modifying by making the length of the minimum wage, it doesn’t phase in by 2030, which is over a decade from now and rolling back paid leave.

VALLAS: So just to sum up because this is, it might just sound like legislative procedure — are you eating another cracker?

SLEVIN: Me?

[LAUGHTER]

VALLAS: Oh my God, there’s more in the package. [LAUGHTER] Folks, we’re not done.

SLEVIN: [INAUDIBLE] if you want one.

VALLAS: Please while you eat I’ll help explain what you just said and why it’s so completely just bananas. So it might sound like legislative process but what you just walked through is that you’ve got workers who organized thousands of signatures, hundreds of thousands of signatures I should say to get a minimum wage increase and a tipped minimum wage increase and paid sick leave all into the November ballot. And all of that was something that overwhelmingly was expected to pass because of the popularity of those policies but when the Michigan Restaurant Association who really didn’t want to see any of this happen was unsuccessful at suing to keep these things off the ballot, that was when we saw Republicans in the state legislature swoop in and say man, we’ve got to keep this one away from democracy because we know we will lose if voters get to make the choice here. And what they realized was that a ballot measure would a 2/3rds vote by the legislature to overturn and they knew they didn’t have the votes to do that but what they did have the votes to do because they do have a majority in the legislature, just not that strong anymore after the midterms.

SLEVIN: For now.

VALLAS: Is that they could set themselves a much lower bar to undo or water it down if they actually passed the laws that they didn’t want to see take effect. Just let that sink in for a second. That is how desperate Republicans in the Michigan legislature are to keep minimum wage increases, tipped minimum wage increases and paid sick leave from happening. They are literally willing to steal those choices from the voters because they know that the voters will approve those measures if democracy is allowed to work. Holy crap.

SLEVIN: Yeah and on top of that they lost the governors race so they’re doing this, they’re not only subverting the will of the voters on these policies, they’re subverting the will of the voters on who is going to represent them and the incoming democratic governor supports these initiatives and the outgoing lame duck Republican governor Rick Snyder opposes them. So they’re subverting democracy in so many ways. There’re going to be many legal challenges to this, it’s likely going to be a very long and costly legal battle so hopefully they will not get away with this. But what does it say about their willingness to even do this, to subvert democracy in such a way and we’re seeing it across the country whether it’s the Georgia governors race and trying to stop people from voting. Whether it’s Rick Scott trying to pack the Supreme Court in Florida before he left. These are not normal actions in a democracy.

VALLAS: No and we’ve gotta to connect the dots also to Maine where this happened just last year as well. We mentioned the DC similarities with Initiative 77 that we have talked about so many times on this show. And in Maine last year voters had approved a ballot measure in November of 2016 that would have brought the tipped minimum wage up to the same level as the regular minimum wage but right after that and because of fierce opposition from the National Restaurant Association you ended up seeing Maine Republicans reverse that ballot measure, keeping the tipped minimum wage in that state down at $5 an hour. So really a trend that we’re starting to see that I think is fair to start to call a playbook that is really clever when you think about it. And the through line here in terms of the evil henchmen that has the wax mustache and the monocle, it’s the National Restaurant Association. I’ve started to call them the other NRA because of how nefariously clever they have become recognizing that raising the minimum wage, eliminating the different tipped minimum wage and paid sick leave, they’re all really popular policies. They’ve learned that when you put them to the voters, they lose, voters win, workers win and so their new strategy and I think the playbook we’re seeing across these states is part one, subvert democracy at all costs even if that means literally undoing what the voters have decided to do. But it also has another sheen to it that we’ve talked about on this show a lot in the context of DC’s Initiative 77, which is instead of showing their own faces and saying we oppose this as restaurants, they’re basically putting up workers, lying to workers, telling them you’re going to lose your tips or you’re going to lose your jobs or whatever other kinds of misinformation.

SLEVIN: And funding these groups —

VALLAS: While they bankroll astroturf campaigns to make it look like workers are the ones opposing these policies so that they you’ve got to legislators saying well I heard from workers that they don’t want to do this.

SLEVIN: And don’t forget, the legislators are all getting funded through their campaigns by the NRA.

VALLAS: That’s exactly right, so they’re funding the opposition to these policies in all kinds of really smart ways of course and anyone who listens to this show can sing it with us but we know what happens when you raise the minimum wage and we know what happens when you bring the tipped minimum wage up to the same level so you have equal treatment of workers. Workers are paid more, they are less poor, they are more financially stable, we know what happens. We also know that restaurant industries stay robust and actually in the states that have done things like raising the tipped minimum wage up to the same level as the regular minimum wage, we’ve seen that restaurant employment is even more robust compared to states that have lower tipped minimum wages so there’s no truth to what the sky is falling, chicken little restaurant lobbyists are saying but they’re having a lot of luck shutting these policies down through this really evil, cleaver playbook and folks really need to be aware.

SLEVIN: Yep. Couldn’t say it better myself.

VALLAS: You’re just gonna leave it there. This is unusual for you.

SLEVIN: I was going to move on.

[LAUGHTER]

VALLAS: I mean, which we should for time. I know, I know, I know, so folks should keep their eyes glued to Michigan where this action is very live as we speak throughout the week, Jeremy’s not keeping is eyes on anything except for his crackers which are still in play, just so you know. So Slevs, in the last few minutes that we have there’s a lot else going on this week, one of the things we would be remiss not to mention although it’s a developing story that I think a lot more will come as the episode is actually going to air is around the farm bill.

SLEVIN: Yeah, so we just found out, here’s when I reveal when we’re taping which is Wednesday, we just found out this evening that there is a deal on the farm bill. That’s both Senators Debbie Stabenow and Senator Pat Roberts who are the top Democrat and Republican in the Senate who had forged the bipartisan Senate farm bill are happy about. We don’t know what that means for nutrition assistance for example but we can hope that if Democrats are backing it that it doesn’t include major cuts. If that is the case, millions of people can breathe a huge sigh of relief that they won’t see their nutrition assistance taken away through the farm bill.

VALLAS: And also a reminder that elections matter because obviously a very different political landscape coming out of the midterms when you’ve got the House flipping into Democratic control which totally changes the landscape when it comes to what a farm bill would do to food stamps and nutrition assistance more broadly. So lots to stay tuned to there as that story develops and we’ll have lots more next week about where that landed as we do know more but one other piece of news to just be aware of and folks who care about poverty and inequality will want to know, Temporary Assistance for Needy Families is also rearing its head again. There’s a new bipartisan discussion draft it’s called that’s actually emerged in the senate so I expect that there’s going to be more to talk about next week as well so stay tuned on the TANF front in addition to the farm bill as both of those stories continue to develop and we’ll have more next week on both fronts. But Jeremy take us home with some of what you’re reading because I feel like we’ve just gone through this parade of horribles as usual. It’s not like it’s atypical for us to have a ton of bad news. But would love to give folks some things to be reading and thinking about that are not just this set of horribles. And I realize as I say that that actually some of these pieces aren’t that themselves all that uplifting either. It’s a mixed bag.

SLEVIN: Let’s start with the uplifting one.

VALLAS: Please, please.

SLEVIN: So this is from our former colleague Greg Kaufmann, it’s in The Nation and it’s called “The New Democratic House Need an Anti-Poverty Agenda”. He puts forward some great ideas for policies that could actually pass the House this session and would help millions of people living in poverty and reduce inequality. I think it’s a great rundown of all the options and a lot of the ideas are ideas we’ve had at the Center for American Progress.

VALLAS: Part of why, just to give Greg extra kudos for this piece, part of why I love this article and I feel like if you’re only going to read one piece this week that’s what should the New Democratic House do? Because everyone’s doing that stuff right now in the wake of the midterms, I would say read this one because, and Greg that’s not just because I love you. It’s because Greg, he highlights all the stuff that people are familiar with. Raise the minimum wage, paid leave, paid sick, there’s a whole set of stuff that’s the usual suspects when it comes to an anti-poverty agenda centers a whole set of anti-poverty policies that don’t ever really get that center stage attention but that would do so much good if they actually got prioritized by congress. And I would hope that some of them might actually be able to have bipartisan support and they have historically, one of the ideas I want to give a little bit of love to because we haven’t talked about it on this show for a long time is subsidized jobs, the idea of helping people who are disadvantaged in the workforce, whether that’s folks with criminal records, people with disabilities, other folks many of whom face a permanent resecession even in a great economy when it comes to the headline statistic of the unemployment rate, these are folks who are disproporitionately shut out of jobs. Something like subsidized employment that could extend more work opportunities with a federal funding boost. A really, really important and timely idea and one that congress would do well to take up. There’s a lot more where that came from, he also mentions actually the Clean Slate Act that Lisa Blunt-Rodchester has a bipartisan bill in congress that relates to last week’s episode around removing barriers to opportunity for people with criminal records. So a lot of good stuff in there Greg and thank you for that piece. Slevs, what else are you reading?

SLEVIN: Alright, I’m going to continue plugging our colleagues. So special shout out to S.E. Smith at Talk Poverty has a piece on crowdfunding in America’s healthcare system. And I think it’s great, I think a lot of people know how common crowdfunding is now for healthcare expenses and everyone, many people know it’s an indictment of our healthcare system but I think S.E. does a really good job at putting it in the context of the broader debate around health care as S.E. writes, “It normalizes the idea that individuals should make decisions about who does and doesn’t deserve care.”

VALLAS: And I don’t want to spoil the piece, you should go read it, you can find all of these articles linked to on our syllabus page of course, but you already knew that because that’s what we do. But the piece is so incredibly gut-wrenching when it comes to the lengths that people are having to go to to meet their basic needs and access the health care services that they’re not able to access through publicly funded means. So really well worth the read and totally gut-wrenching to see some of the stories that they put a face to. So close us out with another piece that actually is also of the season.

SLEVIN: Last one is again Talk Poverty from Pat Garofalo on Black Friday and tying it to the huge massive problem of scheduling uncertainty. Obviously, if it were up to me many people wouldn’t have to work on Black Friday and would get the day off and would have more certain schedules and he does a great job of walking through how that is a daily problem and that schedules often fluctuate or workers earnings fluctuate by over a third because of uncertain schedules.

VALLAS: Yeah so it’s not just Black Friday when that’s an issue although it is one of the times of year when people start to pay attention, a huge problem all year long for such a huge and growing share of the low-wage workforce. So Slevs, I think we’re going to have to leave it there but I think you’ve got one cracker left.

SLEVIN: No, no this is just the peanut butter left at the bottom of the packaging.

VALLAS: I literally don’t have words for what I just witnessed and you’re welcome listeners that this is a radio show without visuals.

SLEVIN: Would have been even better on TV.

VALLAS: You’re welcome that there’s no TV feed for this episode. Don’t go away, next up I’m talking with Professor Jamila Michener about Medicaid and the good, the bad, and the ugly we’re seeing play out in the states on the Medicaid front.

[MUSIC]

You’re listening to Off Kilter, I’m Rebecca Vallas. It has been a hot minute since we talked in depth about Medicaid on this show and there have been a ton of developments, good, bad, and ugly in just the past few weeks on the Medicaid front. So I am thrilled to finally welcome on a friend and colleague who I’ve been wanting to have on this show for ages and that is Dr. Jamila Michener, a professor at Cornell and the author of “Fragmented Democracy: Medicaid, Federalism, and Unequal Politics”. Jamila, thanks so much for joining the show.

DR. JAMILA MICHENER: Thanks for having me. I’m happy to be here.

VALLAS: So a lot of folks have been paying attention to Medicaid in the last several weeks because of so much good news that came out of the midterm elections. It wasn’t just candidates who were on the ballot of course it was also a lot of policies including Medicaid expansion and we had really great news coming out of states like Idaho and Utah and Nebraska where we’ve seen a growing number states joining the ranks of states that have chosen to expand Medicaid under the Affordable Care Act. But great as all of that is, what’s getting a lot less attention by contrast is the ongoing bad and the ugly part of the good, the bad, and the ugly of the Medicaid story and that brings us to work reporting requirements. So before we get into some of the latest news on that front, help rewind the clock a little bit. Help remind us how we got to a place of states being in a position where they now can take away health care from people who can’t find work or get enough hours at their job.

MICHENER: I think that it’s important to have that historical context. It’s worth recognizing that Medicaid is a program that has been with us for over 50 years now. It was part of a slate of social programs that we often think about and call the Great Society programs. And for over 50 years now Medicaid has been providing low-income and a number of other vulnerable populatiosn with access to health care and has saved countless numbers of lives. And for a long time it’s been protected from things like work requirements that have been applied to other social programs like cash assistance programs and food stamps and then we [INAUDIBLE] tacit understand even across the political spectrum that health care was different. And that it wasn’t something that should be contingent on work requirements. And that really changed with the Trump administration and with the Center for Medicaid and Medicare Services, CMS deciding and announcing very early on in the Trump administration that they were open to this possibility of work requirements and once that door was opened by the administration. There were states of course that were waiting in the wings and ready to start applying for waivers for the federal government to allow them to implement work requirements as a part of Medicaid programs. But this was something that’s entirely new as far as health care and Medicaid is concerned. It has been something we just haven’t done until recently.

VALLAS: Now it’s something that if you ask the Trump administration they’re doing it because it’s going to help people. All the language is incredibly orweillian that we hear come out of folks like Seema Verna over at CMS and others who just continue to make this as though it’s about helping nudge people into work and they just need that little nudge to get there. What’s the reality about how these policies play out and what they’re really about, why the proponents are pushing them?

MICHENER: This is great. Even though we don’t have evidence with respect to Medicaid specifically because this has been a program that has been protected from work requirements, we have plenty of evidence about what happens when you implement work requirements in social welfare programs. We know that [INAUDIBLE] at this point from the quote, unquote “welfare reform” in the 1990s under the Clinton administration. And the work requirements that were implemented in that program at that time and we’ve been collecting data and following the numbers and we’ve done studies and gotten a lot of information about the consequences of work requirements are and we have a lot of data to support the argument that this is bad. This is not helping lift people out of poverty.

Even the kind of short term boost in employment for a sliver of people in the immediate wake of the 1990s work requirements for welfare reform disappeared. And instead what we see is people falling deeper into poverty and not really gaining any of the benefits that Seema Verma or the CMS claim they’re going to gain. Instead the obvious gain from the perspective of the federal government right now with work requirements and state governments is that it’s going to cut the Medicaid rolls. It’s going to get people off of the program which for them ostensibly is about pursuing ideological goals around having people not get benefits from the government. And may be about costs, but even the costs argument doesn’t make sense because it’s expensive for people to not have health care, to have to go to the emergency room and to not have preventative care, etc. so the benefits of this are just non-existent. There’s not evidence to suggest that those benefits will materialize or have materialized when we’ve done this for other programs

VALLAS: Now in the wake of Trump administration basically giving states a blank check to take away healthcare from unemployed folks and folks who can’t get enough hours at their job to maintain eligibility for Medicaid if it’s tied to their work status and the number of work hours. We’ve seen a number of states raise their hand and say this is something I want to do. And actually first among those was Kentucky. Kentucky said we want to be the trailblazers in taking health insurance away from mass numbers —

MICHENER: Of all the ways to be a trailblazer.

VALLAS: Right? So Kentucky was the one who laid some of the groundwork there. Ultimately Kentucky’s Medicaid waiver was actually blocked in the courts because it was found that maybe taking health insurance away from unemployed people isn’t consistent with the goals of the Medicaid program. But now we’ve actually see the Trump administration try to bypass that court finding and that’s one of the most recent things we’ve seen in this fight. Bring us up to speed on that news out of Kentucky which obviously has national consequences as well.

MICHENER: Yeah so CMS and the Trump administration have decided notwithstanding the push from the Kentucky court for the federal administration to really consider more closely whether or not the work requirements that Kentucky designed are aligned with the purpose of the Medicaid Act. The Medicaid Act is very clear about what Medicaid is supposed to accomplish and it’s supposed to accomplish getting more people health insurance. So any kind of policy intervention that actually does the opposite of that is suspect as far as what waivers are supposed to do which is improve the implementation of the original law and not undermine it. And so the Kentucky court recognized that and said to the administration you should reconsider this. And they really didn’t, they took some time to twiddle their thumbs essentially and not allow Kentucky to have an approved waiver that looks very much like the original waiver and they have very little to suggest that anything’s really different from the initial problem that the courts identified.

So it will be interesting to see what happens when is ends up back in court. I think that it will because it’s not clear than anything has been resolved and there was a public comment period where a variety of different actors, doctors, hospitals, ordinary people, scholars could comment into the implications of the work requirements in Kentucky. And overwhelmingly the comments for all sectors were negative. There’s almost no one on the ground who’s going to be effected by this who thinks it’s a good idea except for a handful of political elites who have ideological motives. And so when that goes back to the state court hopefully it doesn’t hold muster. But in the meanwhile, hundreds of thousands of people’s health benefits are going to be threatened and that’s really troubling.

VALLAS: Now meanwhile while we’ve got the Trump administration claiming that somehow taking health insurance away from people who can’t find work is good for them, we’ve also got all of this evidence coming out of Arkansas, another state that adopted this policy and where implementation is actually underway such that we have a live look at what happens when this policy or a version of this kind of policy is in force. Tell us a little bit about what’s going on in Arkansas.

MICHENER: It’s a disaster. It’s an unmitigated disaster. Over 12,000 people have been dropped from the Medicaid program in Arkansas simply for a failure to adhere to the work requirements and there’s no indication that those people simply don’t want health insurance. And so one of the things that Seema Verma has recently said in the last few day is well, we have to investigate what’s happening in Arkansas and maybe we’ll learn something. Maybe these are people who don’t want health insurance or who have found work. We don’t really have any evidence to suggest that and there’s very little evidence in part because the [INAUDIBLE] hasn’t required the kind of close evaluation and cracking and collection of evidence would allow them to know what’s going on. And so we’re going into this blind and what we know is tens of thousands of people are losing their health insurance. People who are vulnerable, people who are low income, and there’s really not much of a plan to address it. In Arkansas there’s evidence to suggest that people don’t even know the work requirement exists and so of course they’re not meeting the requirement. I remember shortly after the Arkansas work requirements were implemented I went on to the website, just curious about what it would be like if I tried to navigate it and it was something like 6 AM, I wanted to get to it before my kids woke up. And I couldn’t get on. There were hours, a screen popped up that said you can only do this between 7 AM and 9 PM and I thought oh my goodness, what if I’m in Arkansas and I want to complete my work requirements and I’m trying to get my kids up.

There are so many problems with the administration of this and there are people suffering and the evidence we have about health effects and other negative effects of this comes to fruition in Arkansas and there’s reason to believe it will, it’s going to be bad for people’s health, it’s going to more expensive than the state would have spent had they just covered people and provided them with health insurance. And it’s going to be bad for society and for democracy. All the evidence we have coming out of Arkansas is bad and the Trump administration just hasn’t really acknowledged that and they’ve openly stated that they’re not going to use that as a basis for reconsidering their recent decisions knowing that Arkansas’s a disaster they still approved Kentucky and Seema Verma just recently expressed the desire to approve more states. This is ideological. It’s about pushing a partisan agenda. It’s not about what’s good for regular people who need health insurance.

VALLAS: And I want to focus in on one of the things that you mentioned because boy does it deserve to be repeated for anyone who might have missed it. The Arkansas system is you’re reporting your work hours on a website and that website has limited hours. Who has ever heard of a website that has limited hours? We’re not talking about an office you have to go to. It is a website! That is how hard the system has been designed to access and to be successful with.

MICHENER: It’s absolutely wild. Not to mention the reality of people having limited access to the internet and having to go way out of their way to get access. I mean there are people who have limited access to telephones never mind the Internet. I was in Kentucky a few weeks back at a conference focused on Medicaid and there were actually Medicaid beneficiaries there sharing their experiences. And there were people talking about living in areas that were rural where they didn’t have reliable cell phone reception. So calling the Medicaid office was hard, never mind getting on the internet. We’ve designed a system that’s difficult especially for the very people who are supposed to be using it. People who are low income and who don’t have access to resources. If you wanted to design this badly in a way that harmed people, you would essentially do it just the way Arkansas had.

VALLAS: And in perhaps the understatement of the century, there’s a commission, there’s a non-partisan commission called the Medicaid and CHIP, the Children’s Health Insurance Program, payment and access commission, some people call it MACPAC, it’s job is to advise Congress on Medicaid as well as children’s health insurance policy and they wrote a letter to the Department of Health and Human Services basically warning and stating their concerns with what’s been going on in Arkansas because of these horrifying alarming numbers of people who have already lost health insurance just in a handful of months since this policy went into effect in June in that state. And their exact wording is, “the low level of reporting is a strong warning system that the current process may not be structured in a way that provides individuals an opportunity to succeed.” As I said, perhaps the understatement of the century but coming from a group whose job is to keep an eye on these programs and to weigh in when they see concerns and clearly they do here.

MICHENER: Yeah and the question is really will there but any responsiveness to these different actors who chime in and try to push back against what’s going on. And thus far, there hasn’t been much responsiveness.

VALLAS: Now so help us see how this connects to the broader picture of what’s going on. We’ve talked a lot about Kentucky and Arkansas which are two of the states where there’s been a lot of recent news but they joined a much longer list of states that have advanced these policies through a variety of different means.

MICHENER: Yeah there are five states that already have approved waivers from CMS. So in addition to Kentucky and Arkansas, Indiana, New Hampshire and Wisconsin are supposed to be implementing this. Wisconsin is certainly up in the air now that there’s a different governor who has expressed some doubts about implementing the Medicaid work requirements so it may not happen there. But in addition to those places where waivers have already been approved there are at least ten states with pending waivers, most recently among them is Virginia where part of the legislation that allowed for Medicaid expansion in Virginia also dictated that work requirements would be part of the deal. And this is on the horizon and it’s a possibility for a lot of states that really, states where Medicaid expansion really can only happen if you capitulate to folks who say we’ll only let this happen if there are work requirements. And even states where there’s no expansion on the horizon or expansion already happened through the traditional route.

But now they’re circling back and saying well since we can have work requirements we want them. And it’s really troubling and it’s likely to spread unless there’s a change either in terms of who is in charge at the helm federally or in terms of what happens in the courts and some sort of intervention that makes it less possible for these things to happen but there are literally millions of Medicaid beneficiaries who’s health care is at stake across all of these different states that either have waivers pending or already approved. We’re talking about millions of people who could potentially losing their health care if we continue on the trajectory that we’re on now.

VALLAS: And I’m really glad that you brought up Virginia and the situation that we saw there of there being sort of a hybrid, a deal where you’ve got maybe divided government in a state and you’ve got Democrats really eager to see Medicaid expansion but the pound of flesh that Republicans want to see is tying the expansion to work reporting requirements. That’s very much what we saw play out in Virginia and as you said is potentially at risk of becoming a model for other states. A lot of folks stood up in the wake of that deal and said yeah but you know what, we got Medicaid expansion and hey, maybe it’s a little more complicated and maybe it will just help some smaller number of people have health care but isn’t this still a net good? What do you see as the long term consequences of how this kind of hybrid policy might play out and do you think it’s fair to land in that place as you think about this kind of a compromise deal?

MICHENER: I certainly think it’s nothing to sneeze at to have, I think it’s something like 400,000 people in Virginia who have access to health care who didn’t before. Those folks have needs and they have lives and effort to get them coverage is important and so I don’t want to understate that. But I also don’t want to understate the potential long term consequences of these kinds of compromises. And there are a few things that come to mind. In large part, it depends on how a Medicaid waiver that includes work requirements is implemented. And Arkansas is sort of a worst case scenario or among worst case scenario for how this is implemented. It’s only on the internet, it’s very shoddily done. And maybe Virginia can do a better job and there wouldn’t be as many people who lost their benefits. But that is really a short term, very optimistic way of thinking about the possibilities.

Long term, a probably more realistic way of thinking about the possibility includes considering a number of things. One is what kinds of experience Medicaid beneficiaries are going to have when work requirements are implemented and not just the people who are subject to the work requirements. But really all beneficiaries, because all beneficiaries will have increased requirements to show that they’re not subject to the work requirements and even beneficiaries who may automatically in some way be identified to not have to fulfill work requirements don’t always know that. There are information gaps. And so there might be people who don’t have to fulfill work requirements who don’t know that and who are worried, there are all sorts of administrative burdens and stress and difficulty that will be associated with the experiences that Medicaid beneficiaries have. And I know from research that I’ve done that has consequences for their lives, for how they proceed in their social lives and more importantly in their political lives for how they engage democratically. So definitely long terms consequences such that it’s undermining the political participation and democratic engagement of Medicaid beneficiaries than that is laying a foundation for weakening the political support for Medicaid as a program more generally. And even beyond Medicaid beneficiaries themselves these kinds of policies send signals about what a program is so instead of thinking about Medicaid as an essential program that provides people with a benefit that every person is entitled to by virtue of being a person, which is access to health care. Instead of thinking about it that way, work requirements send the signal that is it a contingent, conditional gift that the government can give you if you’re deserving enough, if you work hard enough. That’s a very different way of understanding the program and it’s a way that erodes public support for Medicaid and weakens the kind of future possibilities for the program and for health care more broadly. And so in the short term we do get an important benefit for many people but in the long term, capitulating to the work requirement approach can weaken Medicaid in a way that could be much, much more harmful than we are likely anticipating right now.

VALLAS: Now one of the pieces and themes throughout your scholarship that I’d really love to get into for this next piece of our conversation is about race and actually structural racism within the healthcare system. Now race has come up I think in the public discourse around Medicaid and work reporting requirements at a few different junctures in particular and most memorably in my mind at least was back in I think it was around May when we saw Michigan republican legislators trying to ram through a set of work reporting requirements through legislation so that was the route that they were taking in that state and it came out when people started to dig into, people including you, how that proposal was going to impact the state’s population that it was going have massively racially lopsided effects the way it was originally drafted and that caused a lot of people pay attention to. Wait a second, is there actually racism baked into these kinds of proposals. But your work over the years has really highlighted that there’s a long history here when it comes to how race has featured and the role it’s played throughout the story of health care in the US. So take us back to the beginning, which is the earlier chunk of the 20th century.

MICHENER: Absolutely. I mean it’s difficult to think of a policy in the United States where race really isn’t baked in from a very early point. And I always say to people when we start talking about the history of race and health care how far back do you want to go? We could go to before the founding. I think that a little bit closer to that, decisions for example, if we think about the Hill-Burton Hospital Construction Act, decisions about where to build hospitals, in which localities to fund for that and who to give the power to decide where to build hospitals and who would have access to those facilities, all of those decisions were deeply racialized in this country and in ways that continue to have consequences now because a lot of these institutions were built in places that were intentionally meant to insure the provision of services to white Americans and to undermine the ability for services to be provided to African-Americans and other people of color and as we work our way through the history of health care.

There are so many example of policies that either explicitly, because sometimes the stuff is pretty explicit but often not explicitly but just by virtue of design that we could predictably understand would have racially disproportionate effects end up negatively impacting populations of color so we can think about things like the closing of public hospitals in cities across the country. And decisions about which public hospitals to close, why to close them, when to close them and all of that is correlated with racial demographics in a city and with political contexts and so race and politics intersect and has historically always intersected in this country in ways that mean health care benefits are channeled towards white Americans and the disadvantages of the health care system, the lack of access to benefits or the instances of retrenchment tend to disproportionately effect people of color.

And we see that with the Medicaid expansion. Nobody designed Medicaid expansion to achieve disproportionate racial effects but when the Supreme Court said hey, states could chose this, guess what, a lot of the states that have the most significant African-American populations also have the most resistance to expanding Medicaid. And when we look at the populations that have lost the most through decisions on the state level not to expand, African-Americans are at the top of the list. And so even through a policy that seems racially neutral like Medicaid expansion, there are effects that are racial and precisely what we should expect with Medicaid work requirements. Michigan was a particularly egregious example because they literally wanted to pick and choose which counties within the state would be subject to the work requirements and it was structured in such a way that the heavily white countries would be exempt whereas very low-income cities would not. And we know who’s in the counties and who’s in the cities. And so there are obvious designs like that where folks like myself and plenty of others said wait a minute, this is going to have heavily racially disproportionate effects and if we pretend that’s not the case we will just perpetuate racial inequalities.

Even when it comes to actual administration of Medicaid work requirements, this is where the rubber really meets the road and colleagues of mine like Joe Soss and others who have done really extensive work and I’ve done work showing that people’s experiences with social programs, in my work I focus on Medicaid both other work that focuses on social programs like cash assistance programs that show that bureaucrats at the front lines, when these kinds of policies are passed they’re making the same decisions about who gets passed through and who gets the hammer laid down on them and we know that those decisions disproportionately disadvantage people of color. and when you don’t have work requirements and you don’t have punitive policy that is excluding particular people from accessing a benefit, you have less of that discretion that ends up being racialized. But the more layers we add on the more difficult we make for people to access benefits, the more that tends to harm people of color. And that happens sometimes explicitly but it happens even when you don’t have any evil person sitting around trying to harm anyone is baked into a lot of the systems and the processes that account for the implementation of social policy in the US. And if we pretend it’s not there it only gets worse.

VALLAS: And a point that you’ve made in some of your work that to me just connects really important dots in a really crucial way is that here you’ve got folks of color already facing persistent employment discrimination and higher unemployment rates and on and on and also being disproportionately likely, for example to have a criminal record that can be in a lot of ways a lifetime sentence to joblessness even if it’s a minor, old record something we actually talked about in our most recent episode at great depth. But then by making healthcare contingent on your work status you’re overlaying all of these different connected and compounding layers of discrimination and that doesn’t even get into the kinds of health care discrimination that people already face on the basis of race, so a lot of interconnected layers there.

MICHENER: Absolutely. We have to pretend as though everyone has equal access to employment if we’re going to make healthcare contingent on employment and the reality is everyone does not have equal access to employment and not for reasons that are arbitrary or about people not taking personal responsibility or having some sort of individual deficits. But for reasons that are systemic and that have to with policy and that have to do with deeper racism that exists in our society. There’s a late sociologist, her name is Devah Pager who did this amazing path breaking work on discrimination in the low-wage labor market. And showed that it was harder for an African-American male without a criminal record to get a job when there was a white male with a criminal record applying for that job. Now, I don’t think a criminal record should be a barrier to anyone getting employment honestly. But what that study showed that irrespective of a lot of factors, just being a black person makes it more difficult to find employment in the low wage labor market and not like trivially more difficult, substantially more difficult. So what does it mean then knowing that? And we know that, we know that. What does it mean knowing that to say but you can only have healthcare if you have a job? We’re just taking deeply engrained systemic racism and amplifying its effects, carrying over its effects in one arena, which is the labor market to other arenas like healthcare. And those are the arenas already having their own problems with race and now we’re just compounding the problem. And we’re doing it through public policy and we’re doing it knowingly because these facts, this research, it’s openly known.

VALLAS: Now in the last couple of minutes that I have with you Jamila, one of the things that your book “Fragmented Democracy” gets into in detail and I find just fascinating is and you mentioned it just briefly before and I really want to connect this dot as well, is the impact on political participation and participation in democracy that these kinds of policies can have. Part of what your book really specifically gets into is the political effects of Medicaid policy choices. Tell us a little bit about that and part of why I’m asking that question is is it fair to say that these kinds of policies, these Medicaid cuts in disguise as work reporting requirements are they sort of a veiled ideological attempt just through another means at voter suppression of voters of color?

MICHENER: That’s a great question. It’s not obvious to everyone that there should be a relationship between something like Medicaid and voting, or political participation. But what political scientists know is that you vote every two years or you vote every four years and some people even less frequently than that. That is not the primary way that we experience the government in our lives. Especially for people who rely on social programs, especially for people living in poverty. They experience the government in much more concrete ways than that. When there are resources that they need that they’re not able to get access to without somehow interfacing with the government whether that is food or health care and in the case of health care you have over 70 million Medicaid beneficiaries for whom this is a primary way that they interact with the government. And that’s not without consequence. It’s consequential not only because of what it means for their access to healthcare for their health and wellbeing. But because given our limited interactions with the government in life more generally, when there is this major way that we’re interacting in order to try to access a crucial resource in our life, it shapes the way we think about the government the way we think about politics, the way we think about our place in it. So people’s experience with Medicaid matter, and they matter with respect to whether or not people are empowered or disempowered. So in my book I show how these experiences shape the way that people think about government and politics, and then the way that they behave politically, whether they’re willing to act both through voting and through other ways of engaging their local and state governments. And so there are democratic consequences to what we do with Medicaid.

In a paper that I’m working on and that’s going to be published very shortly with a colleague of mine named Jake Haselswerdt we look explicitly at what disenrollment does. So when there are maps of Medicaid disenrollment do we see less voting in the wake of that? And the answer is yes. And work requirements are essentially a tool for massive disenrollment. And so it’s a very real way to send a message to people that the government does not care about that, that they don’t matter in the eyes of the government and so they shouldn’t bother engaging. And people get that message loud and clear. And they adjust their political behavior accordingly and that means that our democracy is weaker. And it’s not weaker in a way that is even distributed. It’s weaker in a way that is excluding the already most marginalized voices, people living in poverty, people of color. and that is dangerous because it undermines the very notion of what democracy should be. Whether or not this is an explicit voter suppression tactic I have no doubt that there are people who would see that as a benefit.

One of the things people would say to me when I was writing this book is oh no you’re telling people that you can exclude folks politically by taking away their Medicaid, isn’t this going to motivate people to take away Medicaid. And oen of the things I said is the folks who want to do that didn’t need my book.

VALLAS: Yup.

MICHENER: They know that you take and you take and you take from people and it alienates them from the government and those are precisely the people who some people [INAUDIBLE] to want to alienate. But I can’t pretend what’s in any political elite’s heart and mind. I also don’t care because whether they intend it or not it happens and so the folks who are making these policies should be held accountable for those outcomes and they should be held accountable for how their actions are effecting our democracy.

VALLAS: I’ve been speaking with Dr. Jamila Michener, she’s a professor at Cornell, she’s also the author of the book we were just talking about, “Fragmented Democracy: Medicaid, Federalism and Unequal Politics”. You can find that on our nerdy syllabus page along with some of her other writings of course. Jamila, thanks so much for taking the time and for connecting all of these dots for us, ugly as this story is.

MICHENER: Thanks for having me.

VALLAS: And that does it for this week’s episode of Off Kilter, powered by the Center for American Progress Action Fund. I’m your host, Rebecca Vallas, the show is produced each week by Will Urquhart. Find us on Facebook and Twitter @offkiltershow and you can find us on the airwaves on the Progressive Voices Network and the WeAct Radio Network or anytime as a podcast on iTunes. See you next week.