It has been overshadowed by months of Democratic infighting and the searing national debate over Jan. 6, but the Biden administration is quietly erasing one of the cruelest legacies of Donald Trump’s presidency. This is a genuine achievement, in both symbolic and practical terms.
When Biden took office, nearly 20 mostly Republican-controlled states were in the process of crafting work requirements for Medicaid, on which 76 million Americans rely.
Now, Medicaid work requirements are all but dead in all those states.
That erases a legacy of the Trump administration, which had invited states to submit proposals to impose such requirements. Proposals were eventually approved for 12 states — all with Republican legislatures, governors or both — while a half-dozen others were pending when Trump left office.
In the most visible case, under Arkansas’s 2018 requirements, nearly 17,000 people lost health coverage. That wasn’t necessarily because they weren’t working. It was mainly because it was so difficult to satisfy all the reporting requirements.
Which is a feature, not a bug, of work requirements. By forcing recipients to prove they’re working and navigate a bureaucratic maze to stay in the program, the state gives itself an excuse to kick off those who make a paperwork mistake or miss a reporting deadline.
Biden’s reversal began just after he took office. In February, the administration informed states that it was preparing to withdraw approvals for work requirements granted under Trump.
One by one over the following months, those approvals were either rescinded by the administration, held up by court challenges, or delayed by state governments that expected the policy reversal (in Utah, officials suspended requirements due to the pandemic). Georgia was the last state where approval for this policy was still in force, though Republican states may still wage court battles.
Legacy of cruelty
Trump’s effort to impose Medicaid work requirements was part of a much larger campaign to undermine and roll back our country’s fitful advance toward universal health care. This constituted an even broader legacy of cruelty, and arguably outright betrayal.
That’s because Trump campaigned in 2016 as a corrective to Paul Ryan-style Republicans who had treated destroying the social safety net as a quasi-religious calling. Trump vowed that “everybody’s got to be covered,” and insisted no one would die on the street, uninsured.
But once in office, Trump embraced GOP anti-safety-net zealotry by going all in on the Republican effort to destroy the Affordable Care Act. Driven by hatred of Barack Obama, he endlessly raged that the ACA was a “disaster.”
That culminated in the 2017 repeal attempt, which fortunately failed. Stymied in that effort, which would have taken coverage away from millions on the ACA’s Medicaid expansion, Trump sought to weaken the safety net via other administrative means, such as these Medicaid work requirements.
And so, in erasing those requirements, Biden is also erasing a larger hangover of Trumpian cruelty.
The ACA is expanding
This legacy is being erased in another way. Under Biden, the same ACA that Trump tried to destroy is expanding and moving toward realizing its potential. A record number of more than 13 million people have signed up for 2022 coverage on the exchanges.
A key reason for this is that the covid-19 rescue plan that Biden signed in March expanded the number of people eligible for ACA subsidies and beefed up subsidies for those already eligible. As Margot Sanger-Katz details in the New York Times, this is a real achievement: It substantially reimagines and expands the ACA amid a pandemic, meaning the ACA is rising to an emergency occasion.
Still, this achievement is at risk. The ACA expansion in the rescue package expires at the end of next year, and while Democrats want to extend it in the Build Back Better bill, a certain West Virginia senator remains opposed. That would be a policy and political disaster for Democrats.
“If Democrats aren’t able to extend it, millions of people will get notice of huge premium increases right before the midterm election,” Larry Levitt, executive vice president for health policy at the Kaiser Family Foundation, told us.
In short, the pandemic has not dimmed the GOP desire to roll back that ACA expansion and undermine Medicaid, even as we face a new covid surge. But now, with the Georgia decision, work requirements are effectively dead — as long as a Democrat remains in the White House.
Biden has made serious mistakes with the pandemic, in particular the failure to secure enough covid tests when need has exploded. But he’s making progress in getting more Americans covered, replacing the Trumpian impulse to impose suffering for the sin of being poor with the principle that every American ought to have access to health care.
“Biden has quietly been moving us closer to universal coverage, picking up on a cause Democrats have been pursuing since the early 20th Century,” Jonathan Cohn, author of an excellent history of the ACA, told us. “A big part of that has been undoing the legacy of Trump.”