In July of 1965, Lyndon B. Johnson signed into law the Social Security Amendments, establishing Medicare and Medicaid, health insurance programs for the elderly and the poor. Johnson envisioned that the sweeping reforms of his presidency would make possible a “Great Society” in America, a future free of economic and racial injustice.
Johnson’s vision of public programs and services as the backbone of a socially just nation finds its antithesis today in the social vision of the Trump administration, which seeks to eliminate virtually every public-funded social service and destroy the segments of the population which rely upon these services. The latest installment in the administration’s chronic assault on human rights came as the Administrator of the Centers for Medicare and Medicaid Services issued a state directive guidance for proposals to require employment for Medicaid eligibility.
Since the issuance of this directive, two states – Kentucky and Indiana – have had their Medicaid waivers approved by CMS. In practice, the waivers will bar anyone who cannot provide proof of employment and of having worked at least 20 hours per week from accessing Medicaid coverage. They also permit the state to bar coverage from Medicaid enlistees who are late to file annual paperwork establishing eligibility. This means that those who are late to file the paperwork for Medicaid eligibility “redetermination”—which requires official documentation of proof of income and family size—are locked out of the system entirely, for 3 months in Indiana and 6 in Kentucky.
Secretary for Health and Human Services Alex Azar announced Indiana’s approval days after being sworn into office. “Today’s announcement is just one step in a long legacy of innovation,” Azar said, standing in a public hospital in Indianapolis, where, the Washington Post notes, “nearly half the patients rely on Medicaid and almost one in five is uninsured.” If jeopardizing the access to healthcare coverage of 130,000 people is innovation, Indiana is on the right track, for this is the number of residents currently covered by Medicaid who do not meet the new work requirements and whose coverage will be compromised if they are not able to meet them.
That any person can be denied access to healthcare because they can not pay for it is a travesty. Imagine every visit to the hospital, general physician, dentist, psychiatrist—or another medical practitioner—you have ever had. Now imagine they were all impossible. The emergency gallbladder surgery that saved your life? It could cost upwards of $20,000 out of pocket. Your trip to the ER for injuries from a car accident? Simply riding in the ambulance could cost hundreds, if not thousands of dollars. Without health coverage, the medical services and procedures people need to survive are impossible to access, and every medical malady becomes a life or death situation. In fact, a 2009 study published in the American Journal for Public Health found that 45,000 Americans die annually as a direct result of not having access to healthcare. Many of these deaths, caused by common chronic ailments like hypertension, diabetes, or heart disease, could be easily prevented with access to the proper medical treatment. The number of deaths caused by lack of health coverage, the study reported, now exceeded those caused by other common killers like kidney disease.
Yet the rhetoric around uninsured Americans emphasizes choice and blame, rather than needs or rights. As House Oversight Committee Chair Jason Chaffetz famously said in reference to the ACA in 2017, “Americans have choices. They’ve got to make a choice. So rather than getting that new iPhone that they just love and want to go spend hundreds of dollars on that, maybe they should invest in their own healthcare.”
Chaffetz, who has consistently opposed the Affordable Care Act, same-sex marriage, net neutrality, mandatory vaccinations, and the scientific consensus on climate change, glibly dresses his hatred for the poor in the language of agency and moral blame. Why don’t the poor just spend thousands of dollars on healthcare they can’t afford, Chaffetz asks, instead of spending hundreds of dollars on the cell phone they use regularly and can afford? Why, I must ask, does Jason Chaffetz resemble so closely the product of performing extensive plastic surgery on a rodent? Questions abound.
In all seriousness, advocates for cutting Medicaid funding and making access virtually impossible employ patronizing rhetoric concerning the need for the poor to “make [smart] choices,” and for those who have been successful in society to “empower” the poor to get jobs — as if it’s impossible to simultaneously work hard, make smart decisions, and be poor. In fact, it is the “working poor” that makes up the majority of poor people in America. Accordingly, independent study after independent study has shown that the majority of those enrolled in Medicaid who are eligible and able to work are already doing so. It is those who are poor and cannot work due to an illness or disability—a group already at extraordinary risk for the myriad types of violence which make access to healthcare so critical—who are made especially vulnerable by restrictions on access.
The imposition of external requirements and harsh, prohibitive penalties for late paperwork are clearly intended not to “empower” the poor, but rather to bar them en masse from accessing the care they need. Since the implementation of the six-month lock-out policy for late paperwork in Indiana in 2015, 91,000 people have been kicked off of Medicaid. State officials estimate that about half of those people are still eligible for Medicaid today and are not receiving it.
The moral turpitude of the Trump Administration and its actions cannot be understated. We all, as Chaffetz wisely noted, “have choices.” The choice to deny coverage to thousands of people and allow thousands more to die from ailments otherwise easily treated by medical professionals is not something of little consequence – it is vile and evil. The move to cut funding and restrict the poor’s access to healthcare is motivated by anything but a desire to help people in need; rather, this line of thought and action is motivated by a deeply unjustified hatred for the poor and a malicious desire to see them destroyed. I can think of no other explanation for a movement which seeks to deny fundamental human rights and cause the unnecessary deaths of thousands of people.
In no other developed nation on Earth could this absurd and inhumane scenario take place. Yet the United States, the richest country in the world, is also the only developed nation which does not guarantee basic access to healthcare for its citizens. While other countries provide their citizens universal healthcare, in which the government funds healthcare for all, or use a single-payer healthcare system, in which the state singularly organizes funding while care stays in private hands, the United States employs neither, instead relying upon a convolutedly unregulated market system of health insurance coverage.
Many critics of the American healthcare system saw promise in the Affordable Care Act, or Obamacare, as a light of hope for healthcare reform. By expanding Medicare and Medicaid coverage to millions of people previously uninsured, the ACA helped to secure healthcare for many who would have lived in peril without. It also required people to purchase private insurance policies while partially subsidizing those policies with government payments to private insurers.
Yet the fact is that millions of people today remain uninsured under the Affordable Care Act, opting to pay the $700 penalty fee—commonly known as the Obamacare tax—to waive insurance because they cannot pay for the insurance itself. And while the percentage of uninsured Americans reached an all-time low in 2016 due to the ACA, the underreported reality remains that growing segments of “insured” populations are underinsured, and cannot pay their medical bills. As Physicians for a National Health Program, a single-payer advocacy group, writes, the ACA provides neither legal reform for “our fragmented financing system” nor the “unfair financing of healthcare, whereby costs are disproportionately borne by middle- and lower-income Americans and those families facing acute or chronic illness…Insurers will continue to strip down policies, maintain restrictive networks, limit and deny care, and increase patients’ co-pays, deductibles and other out-of-pocket costs.” By 2023, PNHP predicts, “about 30 million people will still be uninsured, and tens of millions will remain underinsured.”
In each state that implements work requirements or lock-out penalties for late paperwork submission, thousands of people are at risk for being denied health coverage. Thousands will die deaths that could have been prevented; thousands of families, friends, and lovers will grieve for lives that could have been saved. This is the cost of human life, a cost that will only increase as the Trump administration implements progressively severe restrictions to accessing healthcare, amongst other social services like public education, subsidized food, and housing. In Trump’s Great Neoliberal America, there is no room for the poor, the homeless, the unemployed, the indigent—the most vulnerable, and therefore most undesirable and most expendable segments of the population. Trump’s America is one in which there is no care for human life beyond value in dollars, in which the wealthy and powerful eliminate lifelines to food, shelter, and healthcare, and then watch from afar as the poor die sick in the streets.