Like most Republicans, Mississippi Gov. Phil Bryant is an Obamacare refusenik. A staunch opponent of the law, he rejected the Medicaid expansion, refused to build an exchange, and won’t encourage Mississippians to enroll in the federal backstop.
All of this is why, according to a recent report, the number of uninsured in the state has grown since last year, when Obamacare went into effect. As of this month, Mississippi has an uninsured rate of more than 21 percent, a 3.34 percentage-point increase over the previous year. By contrast, West Virginia—a similarly poor state that took the opposite approach—has seen its uninsured rate decline from more than 17 percent to an estimate of less than 7 percent, a slightly more than 10-point drop.
Obviously, the bad news made its way to Gov. Bryant. But rather than take responsibility for the consequences of his policy choices, Bryant set a new standard for chutzpah and blamed President Obama. “If statistics show that the ill-conceived and so-called Affordable Care Act is resulting in higher rates of uninsured people in Mississippi,” said Bryant, “I’d say that’s yet another example of a broken promise from Barack Obama.”
So Obamacare’s namesake is responsible for the fact that you can’t be bothered to assist your least well-off residents? It’s a hilarious and pathetic attempt to evade responsibility, if not that surprising; on Thursday, after withdrawing a bill for additional border funding, House Speaker John Boehner slammed Obama for not taking further action, as if he’s responsible for the GOP’s failure (this, the same week the House authorized Boehner’s lawsuit against the president for allegedly overstepping his authority).
But the important point isn’t that Bryant is incoherent, it’s that his inaction—and the inaction of other red states—was predictable. Any time the federal government delegates anti-poverty policy to the states—from Medicaid and food stamps to Temporary Aid for Needy Families and unemployment insurance—some states embrace the programs, providing decent (or even expansive) services, while others adopt the least generous approach available.
Conservative readers might quibble and argue the opposite, that—in the words of a recent Atlantic piece from Richard Epstein and Mario Loyola—a “relentless expansion of federal power” has replaced the “ ’laboratories of democracy’ with heavy-handed, one-size-fits-all solutions,” turning the states into “mere field offices of the federal government.”
This is … exaggerated. Take Medicaid. Yes, it has federal requirements for funding. Expansion aside, if a state doesn’t follow the rules, it loses its share of Medicaid funding. But these rules are basic, and amount to a simple agreement to provide health insurance to the poor. (Indeed, the kind of state that would begrudge requirements like covering adults with children is probably not the kind of state that would build its own insurance program absent federal action.)
Outside of the basics, however, states have considerable discretion in how they tailor their programs. In keeping with their histories as low-tax, low-service states, places like Alabama and Mississippi have aimed for the minimum, providing as little as possible to poorer residents. Neither state offers benefits to childless adults, and both extend benefits only to people far below the federal poverty line (23 percent of the line for Alabama and 29 percent for Mississippi). That captures the poorest residents, but it excludes tens of thousands of poor and low-income households who make no more than a few thousand dollars.
According to the Kaiser Family Foundation, a family of three in Alabama has to earn less than about $4,500 to become eligible for Medicaid. Anything more and they can’t use the program. Other states—like Louisiana, Kansas, Texas, and Virginia—have similarly low eligibility requirements. These high bars (of sorts) are all but designed to keep as few people on Medicaid as practical, despite the obvious costs of low-income families and communities having no insurance.
Overall, the flexibility of Medicaid and the Affordable Care Act allows stingy states to “innovate” by keeping benefits as low as legally possible. And the same is true of TANF, which—like Medicaid—allows for broad discretion among states. In a 2012 study, the Urban Institute illustrated this with case studies from California, Washington, Michigan, Florida, and Texas. California provided a platform “of extensive education and training opportunities,” and Washington tried to “make work pay.” Their income threshold for cash assistance (at the time, $1,203 a month and $1,122 a month, respectively) was much higher than their peers’ ($393 a month for Florida and $401 a month for Texas), and their actual assistance was more generous, too. Compared with many states, California and Washington provide actual safety nets, versus the programs in Texas and Florida, which seek to remove recipients as quickly as possible by providing as little as possible.
Ultimately, the result of variation and flexibility for TANF has been a hodgepodge of programs across and within states. “[T]here is no national TANF program,” the Urban Institute pointed out, “but rather a different program in each state.” For as much as this might be desirable in some places, it also poses serious problems in others. “Its capped block grant structure,” a feature it shares with Rep. Paul Ryan’s anti-poverty proposals, “meant that federal funding did not go up with the increase in need as it did for SNAP and Medicaid. States, caught in a deep fiscal hole, were not able to increase their resources in response to need.” Our so-called laboratories of democracy weren’t there when people needed them the most.
If your goal is to enhance federalism and encourage state experimentation, these aren’t huge issues. It’s why block grants have been a recurring feature of Republican policy reform, from “Government for Tomorrow”—a 1965 pamphlet from the Republican Governors Association and the Ripon Society—to, again, the new plan from Ryan. (He calls them “opportunity grants.”) But this comes with clear disparities in state-to-state assistance—it’s far better to be poor in Massachusetts than North Carolina—and real weakness in the face of recessions.
By contrast, if your goal is a little less abstract—if it’s simply to provide adequate assistance for as many people as possible—then these hoops are unnecessary. Maybe we want the states to be field offices for Washington, which—for all its faults—does a pretty good job of cutting checks. That’s not to say there isn’t virtue in the “laboratory” idea; different states do have different needs on a variety of issues. But poverty in Virginia doesn’t look that much different from poverty in New York, and there’s no need to pretend otherwise for the sake of federalism.
I’ll be honest. In a real sense, this is taking safety net programs out of the hands of voters (or at least, voters who participate in state government elections), and shifting power toward bureaucrats in Washington, which will come with real tradeoffs in responsiveness and accountability. With that said, our existing federal safety net programs are relatively well-administered by Washington, and Congress can still make substantial changes to their shape and operation. (See last year’s major cuts to food stamps.) What’s more, we shouldn’t ignore the tradeoffs of conservative policy: The more autonomy you grant to individual states in anti-poverty policies, the less coverage there is for low-income Americans.
This isn’t a hypothesis. Thanks to the Supreme Court, millions of low-income Americans languish in states that refuse to expand Medicaid. (I’ll add, as an aside, that it’s no coincidence that the majority of these people are low-income blacks living in the South.) The simple fact is that some states just aren’t interested in running a social safety net.
Let’s mock Gov. Bryant’s excuse-making on the rise of his state’s uninsured. It’s absurd and hilarious. But let’s also remember that his choice is only possible because we allow states too much discretion in administering the welfare state. On a whole constellation of issues, federalism has its place. But when it comes to sending help to poor people, let’s set it aside.