When the Affordable Care Act (ACA) was passed in 2010, it undertook a major expansion of Medicaid—a public assistance program that offers healthcare to low-income families. However, Medicaid expansion was challenged when the Supreme Court ruled in National Federation of Independent Business vs. Sebelius that the federal government’s plan to impose expansion on state governments was unconstitutional. This was the much-discussed “Roberts swing-vote case.” The Court’s ruling gave state governments the license to cut or expand Medicaid at their own discretion . As a result, important discussions have been sparked in many states on healthcare policy and the future of Medicaid—specifically whether their states will expand or cut Medicaid.
Absent from these discussions -or implicit in them- is how the structure of healthcare in the United States, beyond just the services provided, shapes the social realities of those in need. The division of US healthcare into two distinct programs—Medicaid and Medicare—has in effect categorized the most impoverished citizens in the country into two classes of citizens.
Looking critically at the structure of healthcare, the distinction between these programs reinforces a long-held perception among the American public: there is a deserving and an undeserving poor. More broadly speaking, current healthcare policy demonstrates how US welfare, even while providing important services, stigmatizes those in need.
The desire to make distinctions among the receipts of welfare is not a new concept. Over the past century, it has been reformed and repurposed through welfare policy and public discourse. If we are to have a productive discussion about Medicaid and the future of healthcare in the United States, these narratives of the poor imbued in welfare policy must be recognized.
While there may not be demarcated lines to pick up welfare checks, in contemporary welfare policy there is an unarticulated ontological distinction between the unfortunate and the irresponsible, or the pitied and the blamed. This classification starts with the term “welfare”—which has acquired moral valences and a narrowed meaning in the past half-century. Welfare, by definition, means far more than it does in common use today. All government programs that seek to insure a basic standard of well being for citizens could be understood as part of the welfare state. However, our label of “welfare” today is limited to forms of public assistance (i.e. food stamps and unemployment), according to New York University historian Linda Gordon. This limitation excludes social security, disability, and disaster relief from “welfare” categorization, and places them instead under the label of social insurance. A 65-year-old receiving social security checks in the mail is not considered by the public to be “on welfare.”
Contemporary divisions between public assistance—“welfare”—and social insurance have been integrated into healthcare policy. With the 1965 amendment to the Social Security Act, President Johnson created two new healthcare programs: Medicaid and its assonant cousin Medicare. The programs demonstrate (and reinforced) distinctions between “welfare” and social insurance in American welfare policy. Medicaid, as the program for which people qualify by virtue of their low income, represents the public assistance form of welfare, and Medicare, as the program into which one pays over time, the social insurance form. This separation in policy makes healthcare an interesting lens through which to examine the categories of public assistance and social insurance. How do these categories impact the services offered to and public opinion of welfare recipients?
When Medicare recipients are said to have “paid into” their services, the implicit statement is that they’ve earned healthcare. . This policy approach reflects an understanding in our capitalist society that productive citizens are employed. A lifetime of wages has marked them deserving of superior medical services or medical services at all.
It is this distinction between “paying into” a social insurance program such as Medicare, and receiving “welfare” in the case of Medicaid, that enabled politicians who oppose Medicaid as “federal giveaways” or “free-rides to conversely support Medicare. This sentiment still persists, as demonstrated by when Wisconsin Representative Paul Ryan came under fire for an appearance on a morning talk show where he discussed his anti-poverty proposal, stating that poverty has been rooted in a “tailspin of culture in our inner cities,” explaining that there are “generations of men not even thinking about working or learning the value and the culture of work.” Ryan is a staunch opponent of the ACA. His budget plan included a $716 billion cut to Medicaid spending and he supported The Patient’s Choice Act, an alternative health care plan that did not include the ACA’s Medicaid expansion. Ryan’s opposition to Medicaid makes sense considering these “inner-city men”—a euphemistic way of referring to the low-income individuals—are undoubtedly the very people being supported by public assistance programs like Medicaid. The “working poor,” who benefit from social insurance programs, are exempted from Ryan’s chastisement.
In support of these comments, Bob Woodson, president of the Center for Neighborhood Enterprise, made Ryan’s implicit commentary explicit: “Woodson is uncomfortably direct here, articulating a narrative that so often goes unspoken, but remains powerful in American politics. As Woodson alludes, there is historical precedent for the conception of a deserving and undeserving poor in the welfare state.
In 1901, British sociologist Seebohm Rowntree made a categorical distinction among the poor. He determined that there were two kinds of poverty, primary and secondary. Primary poverty referred to individuals whose insufficient means resulted in below minimum standards of living. Secondary poverty referred to individuals whose situation would be sufficient if they efficiently used their resources. In some cases, the poor were responsible for their poverty.
While the discipline of sociology moved beyond passing moral judgment on the poor—highlighting the structural causes and economic inevitability of poverty and unemployment—public perception and welfare policy often continued to reflect Seebohm Rowntree’s philosophy. His distinction legitimized a dichotomy that there was a turn-of-fate poverty and a poverty due to lack of ambition (laziness) and prudence (excess). Through the advancement of the welfare state, these popularized distinctions of primary and secondary poverty were cemented in the now common understanding of the deserving and the undeserving poor, cited by Woodson.
These narratives of the poor persisted through moral renunciations of welfare beneficiaries during welfare reform in the 1960s and 1970s. President Ronald Regan included in his stump speeches a criticism of “welfare queens”: women who exploit the welfare system by fraudulently collecting benefits. Simultaneously, the racially laced social theory of a “culture of poverty”—Ryan’s “cultural tailspin” being its most recent iteration—argued that the poor are socialized in a way that perpetuates their socio-economic problems. These were targeted criticisms, just as Shaarff, Ryan and Woodson’s comments were more recently. The “welfare queen” is not a Jewish grandmother in Florida getting her social security checks in the mail every month and a hip replacement on Medicare. The opponents of welfare who use these narratives are often opposing certain kind of welfare (public assistance), which they believe supports a certain kind of poor (the undeserving).
These narratives do not exist within a vacuum. They continue to impact our welfare policy, which is not merely a reflection of policy priorities, but also a way we appraise and perceive citizenship. By labeling public assistance as unearned and, therefore, undeserved, welfare policy has long stigmatized and provided insufficient services for many of those who receive its benefits.
John Hopkins University economist Robert A. Moffit recently conducted a study analyzing fluctuations in government welfare spending. He discovered that between 1983 and 2004, assistance for citizens just above the poverty line doubled. However, the lowest-income Americans have seen their assistance shrink by a third. Moffit points outright to poverty narratives at the cause: “There’s been this emphasis on rewarding workers and people like the elderly or disabled who are considered ‘the deserving poor.’ If you’re not working, the interpretation is that you’re not trying.” Moffits demonstrates generally how our ontological categorization of the poor has real effects on the benefits they receive.
With the recent proliferation of state discussions on Medicaid expansion, health care policy has taken on these narratives. Many states, feeling limited by the clear-cut expansion-or-reduction choice, have advocated for fundamental revisions to Medicaid by including premiums on its services. This new policy, in practice, doesn’t make much sense. The premiums ($25 in Indiana, $10 in Iowa) are often not sufficient enough to cover the cost of filing the paperwork for the premiums. Furthermore, any increase in premium reduces enrollment in the program. Researchers at Texas A&M University found that a move from $0 to $10 in enrollment fees corresponded to a 15 percent drop in enrollment. This policy seems unreasonable. Therefore, it is reasonable to assume that these new premium policies are not rooted in a policy decision, but in principle.
As Gov. Mike Pence, an advocate for the Indiana premium program said, charging premiums “gives Hoosiers the dignity to pay for their own health insurance.” This is not a difficult comment to unpack. Like earlier narratives explored in this article, Pence is contributing to the legacy of identifying an “undeserving poor.” Pence sees himself as doing low-income families a favor, providing them the “dignity” to belong to the category of the “deserving poor” they have so long been denied by paying directly for their welfare services. Unlike Ryan or Woodson, however, this narrative is not just words coming out of a politician’s mouth, but the basis for a very real piece of legislation that will undoubtedly impact the lowest-income families on Medicaid in Indiana.
The Conversation We Should Be Having
Avik Roy recently described Medicaid as “America’s Worst Health-Care Policy” in the National Review. Although the author’s claim was rooted in the argument that Medicaid hurts people’s health, Roy does make an interesting point that proponents of Medicaid are afraid to point out its flaws.
Even those who support Medicaid must recognize that the program’s structure has supported the narrative that casts Medicaid recipients as members of the undeserving poor. In policy, these narratives have only served to further underfund Medicaid programs and stigmatize its recipients.
Medicaid at its core is an anti-poverty policy. While it has obvious public health concerns, its foundations are rooted in supporting low-income citizens. For this reason, to challenge the dichotomy between the deserving and undeserving poor does not mean we ought to leave Medicaid unchallenged. Rather, we address how Medicaid policy in its current form sometimes falls short of the needs of those it aims to serve. A conversation on the “deserving” and “underserving” poor, in this way, is a distraction from this important conversation.