tag:theconversation.com,2011:/africa/topics/block-grants-35723/articlesBlock grants – The Conversation2021-07-23T12:12:41Ztag:theconversation.com,2011:article/1601552021-07-23T12:12:41Z2021-07-23T12:12:41ZThe Trump administration feuded with state and local leaders over pandemic response – now the Biden administration is trying to turn back a page in history<figure><img src="https://images.theconversation.com/files/412521/original/file-20210721-19-1bo2ds5.jpeg?ixlib=rb-1.1.0&rect=0%2C5%2C3681%2C2445&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">President Biden and Vice President Harris met on Feb. 12, 2021, with governors and mayors to discuss supporting them in the fight against COVID-19. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/president-joe-biden-and-vice-president-kamala-harris-meet-news-photo/1301799167?adppopup=true">Pete Marovich-Pool/Getty Images</a></span></figcaption></figure><p>As the U.S. recovers from the pandemic, the Biden administration is working to rebuild relationships across levels of government, from the top to the bottom, that were strained during the presidency of Donald Trump. </p>
<p>In November 2020, <a href="https://thehill.com/homenews/campaign/527241-biden-pledges-to-work-with-mayors">Biden</a> offered urban leaders a seat at the table in coronavirus recovery efforts, promising to avoid partisanship. Addressing the National League of Cities in March 2021, <a href="https://www.whitehouse.gov/briefing-room/speeches-remarks/2021/03/08/remarks-by-vice-president-harris-at-national-league-of-cities-conference/">Harris praised</a> urban leadership on COVID-19 – <a href="https://www.newyorker.com/magazine/2020/05/04/seattles-leaders-let-scientists-take-the-lead-new-yorks-did-not">cities like Seattle</a> and <a href="https://www.brookings.edu/blog/future-development/2020/04/07/coronavirus-lessons-from-new-york-and-san-francisco/">New York</a> were among the first to respond to the pandemic, developing testing protocols, tracking new infections and supplying equipment for hospitals – and highlighted the administration’s plans to help pay for improvements to local infrastructure. </p>
<p>The <a href="https://www.cnbc.com/2020/04/09/why-states-and-the-federal-government-are-bidding-on-ppe.html">COVID-19 crisis highlighted</a> the importance of government leaders working together. </p>
<p><a href="https://wwnorton.com/college/polisci/american-government12/brief/ch/03/outline.aspx">The U.S. government system, called federalism</a>, shares power among the national, state and local governments. This system allows local control over most day-to-day government decisions. Local control means that policies can be tailored to the needs and limitations of each community. </p>
<p>But with the onset of COVID-19 in early 2020, tensions in this shared system <a href="https://doi.org/10.5055/jem.0549">boiled over</a>. Instead of collaborating, the federal government <a href="https://doi.org/10.1177/0275074020942060">rebuffed state and local governments</a> desperate for critical information and lifesaving supplies. </p>
<p>States and cities competed over medical equipment, testing capacity and supplies and other needs. Densely populated cities, many feuding with the federal government, were hardest hit. </p>
<p><a href="https://doi.org/10.1111/puar.13243">Federalism seemed to fail</a>, slowing the response and leading to deaths. </p>
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<a href="https://images.theconversation.com/files/412555/original/file-20210722-15-15sk4ec.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Washington, D.C. Mayor Muriel Bowser" src="https://images.theconversation.com/files/412555/original/file-20210722-15-15sk4ec.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/412555/original/file-20210722-15-15sk4ec.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=379&fit=crop&dpr=1 600w, https://images.theconversation.com/files/412555/original/file-20210722-15-15sk4ec.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=379&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/412555/original/file-20210722-15-15sk4ec.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=379&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/412555/original/file-20210722-15-15sk4ec.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=476&fit=crop&dpr=1 754w, https://images.theconversation.com/files/412555/original/file-20210722-15-15sk4ec.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=476&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/412555/original/file-20210722-15-15sk4ec.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=476&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Washington, D.C., Mayor Muriel Bowser called successfully in 2016 for raising the district’s minimum wage to $15, stepping in where the federal government had failed to act.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/MayorDistrictofColumbia/03d2c2263ee44f9da7a342153771c682/photo?Query=Muriel%20AND%20Bowser&mediaType=photo&sortBy=&dateRange=Anytime&totalCount=649&currentItemNo=5">AP Photo/Manuel Balce Ceneta</a></span>
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<h2>Change in approach</h2>
<p>In contrast to the previous administration, the Biden administration is treating local governments as key partners in a variety of areas, including public health. </p>
<p>It has taken steps to give local policymakers more <a href="https://www.nbcnews.com/politics/white-house/white-house-shift-how-vaccines-are-allocated-states-biden-sets-n1266299">control over the allocation</a> and <a href="https://www.nytimes.com/2021/05/04/us/politics/biden-vaccination-strategy.html">distribution</a> of COVID-19 vaccinations, while <a href="https://www.statnews.com/pharmalot/2021/05/05/biden-covid19-vaccine-patent-rights/">setting national policies</a> to hasten the availability of vaccines. </p>
<p>Reasserting closer relationships between the federal government and state and local partners may signal a shift toward more collaboration in general.</p>
<p>The federal government can use its power and position to drive change at the local level. A more collaborative relationship can help the federal government <a href="https://doi.org/10.1111/puar.13257">understand communities’ needs</a>, leading to new policies and priorities. Close partnership may also increase awareness of federal resources that are available, helping state and local governments identify programs to <a href="https://doi.org/10.1177/1078087414530545">better support their residents</a>. </p>
<p><a href="https://doi.org/10.5055/jem.0549">But as our research</a> shows, federal dominance can also be counterproductive. </p>
<h2>How federalism does – and doesn’t – work</h2>
<p>Federal and state governments are responsible for national or regional priorities, such as defense, diplomacy and the raising and redistribution of tax revenues.</p>
<p>But local governments deliver the most-used public services, including schools, transportation, parks and public health. As a result, local governments are perhaps the most important in people’s daily lives. </p>
<p>Local governments both make and implement policy. In areas where the federal and state governments are silent or inactive, local governments often innovate to address community needs. That freedom to innovate helps local governments generate policies that can work their way up and across the federal system. </p>
<p>For example, despite backlash from state and national leaders, <a href="https://doi.org/10.1093/publius/pjx026">various cities</a> – like Austin, Los Angeles, Virginia Beach and Washington, D.C. – have led the way on social and environmental policies, adopting and advocating for <a href="https://www.journals.uchicago.edu/doi/10.1086/708940">higher minimum wages</a>, <a href="https://doi.org/10.1016/j.ecolecon.2015.06.012">fracking limitations</a>, <a href="https://www.acslaw.org/wp-content/uploads/2021/03/The-Rise-of-Second-Amendment-Sanctuaries.pdf">sanctuaries for Second Amendment rights</a> and <a href="https://doi.org/10.1108/PIJPSM-06-2012-0052">reducing law enforcement violence</a>. </p>
<p><a href="https://journals.sagepub.com/doi/abs/10.1177/0160323X0003200202">Scholars have noted changes</a> in the dynamics of these relationships throughout history. During some eras, the federal government has more power over policymaking. At other times, state and local governments exert greater influence. </p>
<p>For example, President Lyndon B. Johnson’s Great Society welfare programs – Medicare, Medicaid and food stamps – <a href="https://millercenter.org/president/lbjohnson/domestic-affairs">increased the federal government’s influence</a> on state and local governments. New federal requirements <a href="https://doi.org/10.1080/07343469.2016.1263979">mandated spending</a> on social programs, often requiring matching funds from state and local governments. And new state and local agencies had to be established to implement federal priorities. </p>
<p>Federal dollars shared with local governments to fight poverty came with <a href="https://fas.org/sgp/crs/misc/R40638.pdf">strings attached</a>. Examples include requirements to meet environmental standards and adopt nondiscrimination policies. </p>
<p>With the advent of welfare reform in the mid-1990s, the <a href="http://webarchive.urban.org/publications/306620.html">federal government relaxed some of these requirements</a>. As a result, state and local governments were given more flexibility over policy and spending decisions.</p>
<p>Our recent research indicates the balance of power in the federal system <a href="https://doi.org/10.5055/jem.0549">affects government performance and the safety of Americans</a>. During the COVID-19 response, the federal government failed to partner with state and local governments. As a result, there were problems finding and delivering crucial supplies like masks and ventilators, leading to needless deaths. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/412539/original/file-20210721-17-5nvegn.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="President Lyndon Johnson, sitting at his desk in a suit, tie and white shirt." src="https://images.theconversation.com/files/412539/original/file-20210721-17-5nvegn.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/412539/original/file-20210721-17-5nvegn.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/412539/original/file-20210721-17-5nvegn.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/412539/original/file-20210721-17-5nvegn.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/412539/original/file-20210721-17-5nvegn.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/412539/original/file-20210721-17-5nvegn.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/412539/original/file-20210721-17-5nvegn.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">President Lyndon Johnson, shown here, expanded the authority of the federal government with his Great Society programs.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/LyndonJohnson/5beacfeddec6446d871b5b0f747dfb6f/photo?Query=Lyndon%20AND%20Johnson&mediaType=photo&sortBy=&dateRange=Anytime&totalCount=1984&currentItemNo=17">AP Photo</a></span>
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<h2>Critical work</h2>
<p>Historically, presidents have taken a range of approaches to managing the federal system. </p>
<p><a href="https://millercenter.org/president/lbjohnson/domestic-affairs">Johnson’s Great Society programs</a> expanded the authority of the federal government. Federal agencies gained the power to create and manage the details of the effort to eradicate poverty, hunger and discrimination.</p>
<p>President Richard Nixon’s “<a href="https://www.doi.org/10.1111/j.1541-0072.1980.tb01181.x">new federalism</a>” sent money in so-called “<a href="http://webarchive.urban.org/publications/310991.html">block grants</a>” to state and local governments to carry out different federal initiatives. This allowed local governments some power over policy design and implementation.</p>
<p>President Ronald Reagan’s “<a href="https://doi.org/10.1093/oxfordjournals.pubjof.a037757">pragmatic federalism</a>” emphasized privatization – using private-sector organizations to deliver services – and <a href="https://journals.sagepub.com/doi/abs/10.1177/0160323X0003200202">decentralization</a>. Reagan used markets to deliver government services through competitive contracts and grants. </p>
<p>In more recent years, scholars have accused Presidents <a href="https://doi.org/10.1093/publius/pjm014">George W. Bush</a> and <a href="https://doi.org/10.1093/publius/pjr020">Barack Obama</a> of returning to the more coercive federalism of Johnson’s Great Society. To encourage state and local governments to adopt federal priorities, federal funds under these presidents again included strings, <a href="https://doi.org/10.1177/0160323X17741723">increasing tensions</a> between these levels of government.</p>
<p>[<em>Understand what’s going on in Washington.</em> <a href="https://theconversation.com/us/newsletters/politics-weekly-74/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=politics-most">Sign up for The Conversation’s Politics Weekly</a>.]</p>
<p>Under President Trump, <a href="https://doi.org/10.1093/publius/pjaa021">these tensions reached an apex</a>. Cities clashed with the federal government over immigration policy, law enforcement violence and health care – and, ultimately, over how to handle the pandemic. </p>
<h2>Biden’s approach</h2>
<p>Much of Biden’s proposed sweeping infrastructure plan addresses problems of rural and urban areas, such as caregiving, clean energy and health care. Other parts confront regional issues, such as transportation, where states play an important role. </p>
<p>With the understanding that coordination among all levels of government helps address problems more effectively, one step Biden might take is to revive the <a href="https://doi.org/10.1093/oxfordjournals.pubjof.a029901">U.S. Advisory Commission on Intergovernmental Relations</a>. This commission operated from 1959 to 1996, offering presidents and federal agencies guidance on issues that spanned the federal system’s layers. The <a href="https://doi.org/10.1111/j.1540-6210.2011.02325.x">commission helped address abuses of power</a> in the federal system and strengthened partnerships between governments. </p>
<p>As scholars, we know that policy issues are rarely independent. Global climate change affects local transportation policies, while health care issues are often closely linked to education and agriculture. </p>
<p>Local governments are important players in the federal system. Over the next year, they will be critical in continued efforts to vaccinate the American public and prepare for disasters like hurricanes and wildfires. </p>
<p>Given the complexity of modern policy problems, renewed consideration of how all levels of government can approach such big issues could help solve them.</p><img src="https://counter.theconversation.com/content/160155/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>People can die when the federal government doesn’t work well with state and local governments – the COVID-19 crisis showed that. But the Biden administration has signaled an openness to collaboration.Ana Maria Dimand, Assistant Professor of Public Policy and Administration, Boise State UniversityBenjamin M. Brunjes, Assistant Professor of Public Policy, University of WashingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/813642017-08-03T01:04:39Z2017-08-03T01:04:39ZHow welfare’s work requirements can deepen and prolong poverty: Rose’s story<figure><img src="https://images.theconversation.com/files/180601/original/file-20170801-9618-1yjlnb6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Losing welfare benefits when they're between jobs can plunge nursing home aides into extreme economic hardship.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/rehab-elderly-people-536383975?irgwc=1&utm_medium=Affiliate&utm_campaign=Hans%20Braxmeier%20und%20Simon%20Steinberger%20GbR&utm_source=44814&utm_term=">GagliardiImages/Shutterstock.com</a></span></figcaption></figure><p>After “Rose” lost her low-wage job in a southeast Michigan nursing home, the single mother of four sought Temporary Assistance to Needy Families (TANF) benefits. </p>
<p>People who are eligible for this federal, time-limited welfare program for very low-income families must be <a href="https://www.theatlantic.com/politics/archive/2017/03/why-work-requirements-in-medicaid-wont-work/520593/">working or looking for work</a>, a feature the Trump administration and other politicians want to spread to Medicaid and other similar programs that support low-income Americans. Rose obtained the benefits but lost them after finding that the program was doing little to help her get a job and interfering with her parenting. </p>
<p>This fairly common experience suggests that these restrictions can prolong and worsen spells of poverty. Like many experts on American poverty relief, I don’t see why that punitive strategy makes sense. </p>
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<a href="https://images.theconversation.com/files/180604/original/file-20170801-15290-xxprax.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/180604/original/file-20170801-15290-xxprax.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180604/original/file-20170801-15290-xxprax.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180604/original/file-20170801-15290-xxprax.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180604/original/file-20170801-15290-xxprax.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180604/original/file-20170801-15290-xxprax.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180604/original/file-20170801-15290-xxprax.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180604/original/file-20170801-15290-xxprax.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Wisconsin Gov. Scott Walker wants to reduce food stamp benefits for families with children whose parents who do not work at least 80 hours a month or meet related requirements.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Wisconsin-Welfare-Reforms/66d979d426fb469aa85aa0650569c344/1/0">AP Photo/Scott Bauer</a></span>
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<h2>Work requirements</h2>
<p>When Rose told me her story while I was researching what happens to women like her, she started by saying, “I’m ashamed.” But it sounded like she wasn’t to blame. She was embarrassed about how she had lost her job, but her explanation showed just how tough a spot she had been in.</p>
<p>After working double shifts for a week straight and completing her duties on a Friday night at about 2:30 a.m., “I dozed off. Me and a coworker,” she said. “It’s documented that it wasn’t even 20 minutes that we had dozed off, and a supervisor walked in. We were suspended at that time.” She got fired shortly thereafter.</p>
<p>Rose enrolled in a local job search program. Some of these programs sent participants on job interviews, but Rose, like many of the 22 women I interviewed, said few got hired. The program wanted her to return to the training site after interviews at the end of the day. </p>
<p>“By that time, the kids are getting out of school. You’ve got to get back home, or you’ve got to go pick the kids up from daycare, and I thought that was pointless to do that,” Rose recounted. “If you didn’t come back, you were considered noncompliant, so you’d be cut off just like that.”</p>
<p>After months without securing a job and struggling to pick her children up from school on time, Rose opted for the “noncompliant” label. This meant losing US$440 a month in TANF payments, her only source of cash income until, six months later and through her own efforts, she found another low-paying job in a different nursing home. During those six months, Rose sometimes couldn’t afford diapers, which meant her youngest child sometimes went without them. When she ran out of food a couple of times, she would send her children to relatives to eat while she went hungry.</p>
<p>Rose’s experience illustrates the downsides of inflexible work requirements. Instead of getting help finding a new job during those six months, she joined the <a href="http://www.urban.org/sites/default/files/publication/27521/412393-Dynamics-of-Being-Disconnected-from-Work-and-TANF.PDF">swelling ranks</a> of families with no cash from welfare or jobs, some of whom wind up scraping by on incomes of <a href="http://www.twodollarsaday.com/">$2 a day or less</a> – a common metric for poverty in developing countries. Typically headed by single mothers, these families are cut off from or otherwise unable to access welfare while also having no earnings. </p>
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<a href="https://images.theconversation.com/files/180607/original/file-20170801-14630-16cum4k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/180607/original/file-20170801-14630-16cum4k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180607/original/file-20170801-14630-16cum4k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=441&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180607/original/file-20170801-14630-16cum4k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=441&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180607/original/file-20170801-14630-16cum4k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=441&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180607/original/file-20170801-14630-16cum4k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=554&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180607/original/file-20170801-14630-16cum4k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=554&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180607/original/file-20170801-14630-16cum4k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=554&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">House Democratic Leader Nancy Pelosi has urged President Donald Trump not to slash funding that helps families with children that are experiencing poverty.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Pelosi-Poverty-Rally/dd2185cfb7504b029536372846547623/4/0">AP Photo/Reed Saxon</a></span>
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<h2>Harsh labor market</h2>
<p>Working on a team with researchers from the Urban Institute, an independent think tank, I found that almost two-thirds of the mothers we interviewed were able to rely upon partners or family members for help. Yet this can <a href="http://www.rsfjournal.org/doi/full/10.7758/RSF.2015.1.1.08">strain the resources</a> of people who are not much better off than them. Some may <a href="https://www.acf.hhs.gov/sites/default/files/opre/dynamicsofdisconnection_finalreport.pdf">lose housing</a>, which leads them to double up with friends, send children to live with relatives or stay in shelters. </p>
<p>Although more research is needed before we know whether lacking access to welfare makes poor families prone to homelessness, families living in extreme poverty are nearly twice as likely to report <a href="http://www.rsfjournal.org/doi/full/10.7758/RSF.2015.1.1.07">housing instability</a> as other low-income families.</p>
<p>You could say that Rose was reaping the consequences of bad choices because she broke a rule. But as I argue in “<a href="https://www.russellsage.org/publications/abandoned-families">Abandoned Families</a>,” my book about the economic and political changes that have thwarted opportunities for upward mobility, the low-wage labor market is harsh. </p>
<p>National data on workplace conditions are scarce, but studies of <a href="http://mysouthsidestand.com/more-news/workers-stories/">cities</a> and certain <a href="http://ssa.uchicago.edu/what-are-hours">occupations</a> have found that unsafe workplace conditions, irregular and unpredictable scheduling, and <a href="https://www.labor.ucla.edu/wage-theft/">wage theft</a> are common. For example, more than 30 percent of low-wage workers in <a href="http://mysouthsidestand.com/more-news/workers-stories/">Syracuse</a> told researchers that their jobs caused a health problem. Many of the women I profiled in “Abandoned Families” told me they worked for employers who violated their rights, and mistakes were greeted with threats of or actual termination. </p>
<p>Should Rose have made arrangements for afterschool care for her children? Perhaps, but it’s not fair to presume that this was a viable option for her. The demand for <a href="http://www.afterschoolalliance.org/Essentials_and_Polling_2013_032713.pdf">care after classes end for the day</a> far outstrips its availability: An estimated 18.5 million more children would be in such programs were they available in their community. Yet <a href="http://www.clasp.org/resources-and-publications/publication-1/CCDBG-Participation-2015.pdf">funding to help low-income parents pay</a> for it is declining. The federal government spent $11.3 billion on child care in 2014, down from $12.9 billion in 2011.</p>
<h2>A poor model</h2>
<p>The frustrating experiences of women like Rose should make policymakers pause before considering <a href="https://www.cbpp.org/research/food-assistance/snap-helps-millions-of-low-wage-workers">extending work requirements</a> to other programs serving low-income families.</p>
<p>Consider the situation with SNAP, the Supplemental Nutrition Assistance Program more widely known by its pre-2008 name, food stamps. More than 60 percent of the households getting SNAP benefits that <a href="https://www.cbpp.org/research/food-assistance/snap-helps-millions-of-low-wage-workers">have children</a> and what budget director Mick Mulvaney likes to call “<a href="https://www.theatlantic.com/politics/archive/2017/05/the-trump-budget-is-the-mulvaney-budget/527700/">able-bodied</a>” adults have at least one employed member. Others are led by working-class people who are hunting for a new job. About one-third of all households with SNAP nutritional benefits earn at least some money from work, according to the <a href="https://www.cbpp.org/research/food-assistance/snap-helps-millions-of-low-wage-workers">Center for Budget and Policy Priorities</a>, a think tank.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/180212/original/file-20170728-18243-1kqbzvh.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/180212/original/file-20170728-18243-1kqbzvh.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180212/original/file-20170728-18243-1kqbzvh.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=594&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180212/original/file-20170728-18243-1kqbzvh.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=594&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180212/original/file-20170728-18243-1kqbzvh.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=594&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180212/original/file-20170728-18243-1kqbzvh.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=747&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180212/original/file-20170728-18243-1kqbzvh.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=747&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180212/original/file-20170728-18243-1kqbzvh.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=747&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">In most households getting SNAP benefits that include at least one nonelderly and nondisabled adult, one or more members were earning money in 2015, even without a work requirement.</span>
<span class="attribution"><a class="source" href="https://www.cbpp.org/research/food-assistance/snap-helps-millions-of-low-wage-workers">Center for Budget and Policy Priorities</a></span>
</figcaption>
</figure>
<p>My study showed that work requirements don’t always help people find jobs. Ultimately, the penalties imposed for failure to meet these rules can wind up punishing low-income kids and prolonging hard times.</p><img src="https://counter.theconversation.com/content/81364/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Funding for the research that is cited in the article was provided by the U.S. Department of Health and Human Services - Office of the Assistant Secretary for Planning and Evaluation; the U.S. Department of Health and Human Services - Administration for Children and Families; the Economic Research Service of the U.S. Department of Agriculture; the Annie E. Casey Foundation; and the Center for Local, State, and Urban Policy - University of Michigan.</span></em></p>Only very low-income Americans who are working or looking for work are eligible for federal, time-limited welfare dollars. This restriction doesn’t always help them get back on their feet.Kristin Seefeldt, Assistant Professor of Social Work, School of Social Work, Assistant Professor of Public Policy, Gerald R Ford School of Public Policy, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/810132017-07-14T02:41:37Z2017-07-14T02:41:37ZWhy health savings accounts are a bust for the poor but a boost for the privileged<figure><img src="https://images.theconversation.com/files/178181/original/file-20170713-9618-8l6p7j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">North Carolina NAACP President Rev. William Barber, accompanied by Rep. Sheila Jackson Lee, Texas, left, as activists, many with the clergy, are taken into custody by U.S. Capitol Police on Capitol Hill in Washington, July 13, 2017, after protesting against the Republican health care bill.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/Search?query=health+care+bill&ss=10&st=kw&entitysearch=&toItem=15&orderBy=Newest&searchMediaType=excludecollections">AP Photo/J. Scott Applewhite</a></span></figcaption></figure><p>When Senate Majority Leader Mitch McConnell released his <a href="https://www.nytimes.com/2017/07/13/us/politics/senate-republican-health-care-bill.html">new version of the Republican health care bill</a> July 13, he relied on a favorite Republican device to solve the nation’s health care woes – Health Savings Accounts.</p>
<p><a href="https://www.ahip.org/wp-content/uploads/2017/02/2016_HSASurvey_Draft_2.14.17.pdf">Health Savings Accounts</a> (HSAs) were established by the same legislation that created the Medicare Part D prescription drug benefit in 2003. <a href="https://www.ahip.org/wp-content/uploads/2017/02/2016_HSASurvey_Draft_2.14.17.pdf">HSAs</a> allow individuals to make tax-deductible contributions, withdraw money tax-free to pay for qualified medical expenses and avoid taxes on the money invested in the account.</p>
<p><a href="https://www.ahip.org/wp-content/uploads/2017/02/2016_HSASurvey_Draft_2.14.17.pdf">Enrollment in HSAs</a> has skyrocketed to nearly 20 million people, but there’s a catch. Very few, if any, of those 20 million people are poor. The HSAs allow individuals to use tax-protected funds for medical purposes for years to come. Some have even called them the <a href="https://www.wageworks.com/blog/2016/july/07/health-savings-accounts-the-new-401k#sthash.eA4uob07.dpbs">“new 401(k)‘s</a>.”</p>
<p>While these savings accounts can be good for people of a certain income level, I have concerns that they will overlook the needs of the poor, who not only stand to gain very little from the tax advantages but who also are unlikely to have thousands of dollars to contribute to such plans.</p>
<h2>Tax savings and a dose of financial responsibility</h2>
<p>Currently, individuals are allowed to make <a href="https://www.ahip.org/wp-content/uploads/2017/02/2016_HSASurvey_Draft_2.14.17.pdf">annual contributions</a> of US$3,400, while families are allowed to contribute up to $6,750. Unlike so-called health Flexible Spending Accounts, or FSAs, left-over assets in the account carry over from year to year. In 2015, the average balance was just over $1,800.</p>
<p>Individuals are able to establish HSAs only when they obtain coverage through so-called High-Deductible Health Plans (HDHPs), which are currently defined as plans with a deductible of at least $1,300 for single people, or at least $2,600 for family coverage. The maximum out-of-pocket cost for individuals and families are $6,450 and $12,900, respectively.</p>
<p>This means that individuals with these plans are responsible for a significant amount of costs before their insurance benefits kick in. There are no data that show how many people of lower income could afford to fund these plans.</p>
<p>What we do know is that there are about <a href="https://www.ebri.org/publications/ib/index.cfm?fa=ibDisp&content_id=3397">20-22 million policyholders</a> with <a href="https://www.ebri.org/publications/ib/index.cfm?fa=ibDisp&content_id=3397">$28 billion in assets</a>. </p>
<p>In larger employers, <a href="https://www.mercer.com/content/dam/mercer/attachments/private/gl-2017-health-national-survey-infographic-series-mercer.pdf">53 percent of employers offer HSAs, and about a quarter of employees are covered</a>. About <a href="http://www.kff.org/health-reform/poll-finding/survey-of-non-group-health-insurance-enrollees-wave-3/">half of individuals</a> obtaining insurance in the individual market do so via a high-deductible plan. This number is expected to <a href="http://healthaffairs.org/blog/2015/10/07/trouble-ahead-for-high-deductible-health-plans/">continue to grow in the future</a>.</p>
<h2>Why are conservatives enamored of HSAs?</h2>
<p>When it comes to conservative ideology, HSA checks off a number of boxes. </p>
<p>For one, they are supposed to empower the individual to take charge of their own health care decisions. With <a href="https://www.jstor.org/stable/1813785?seq=1#page_scan_tab_contents">more “skin in the game,” individuals will be incentivized to make better, more prudent choices</a> when it comes to their health care. This should not only reduce premiums for individuals and families, but equally important, rein in the growth of U.S. healthcare expenditures.</p>
<p>Lower premiums, in turn, would then allow more Americans to obtain insurance coverage. They would also ease the tremendous burden on American companies seeking to provide health insurance to their employees.</p>
<p>HSAs also reduce the tax burden of Americans, albeit mostly for the wealthier part of society. Moreover, the funds in HSAs will provide investment capital to America’s economy and lead to further economic growth.</p>
<h2>Disadvantages of HSAs?</h2>
<p>A handful of studies have been able to provide some insights into potential benefits and problems of HSAs and HDHPs. Most of the studies confirm the general findings of the famous <a href="https://www.rand.org/content/dam/rand/pubs/reports/2006/R3055.pdf">RAND Health Insurance Experiment</a>: Higher deductibles lead to a reduction in the quantity of medical care consumed. The experiment also showed that, on average, this reduction was not detrimental to individuals’ health status.</p>
<p>However, there was one significant exception: Low-income individuals with chronic conditions saw a significant drop in health status.</p>
<p>More recent studies have shown that HDHPs and HSAs lead to spending about <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2910568/">5-7 percent less</a> on medical care per enrollee. Most of these reductions come from <a href="http://www.ajmc.com/journals/issue/2013/2013-1-vol19-n12/medication-utilization-and-adherence-in-a-health-savings-accounteligible-plan/P-1">reducing the amount of care consumed</a> – <a href="http://www.nber.org/papers/w21632?utm_campaign=ntw&utm_medium=email&utm_source=ntw">not from shopping for cheaper providers</a>. There is also evidence that individuals <a href="http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_152.pdf">delay care</a>, <a href="http://www2.deloitte.com/content/dam/Deloitte/us/Documents/life-sciences-health-care/us-lchs-dig-deep-hidden-costs-112414.pdf">do not comply with doctors’ treatment plans</a> and <a href="http://content.healthaffairs.org/content/31/12/2641.full.pdf+html">are unaware of free preventive services</a>.</p>
<p>None of these findings is surprising.</p>
<p>We know that <a href="http://www.bankrate.com/banking/savings/survey-how-americans-contend-with-unexpected-expenses">many Americans do not have enough savings to account for an emergency</a>, medical or otherwise. The wealthiest Americans disproportionately benefit from these insurance arrangements. Indeed, <a href="https://www.cbpp.org/blog/trump-house-gop-health-savings-account-proposals-would-mostly-help-wealthy-not-uninsured">families making in excess of $100,000 make up 70 percent of HSA contributions</a>. </p>
<p>CNN Money called HSAs “<a href="http://money.cnn.com/2017/05/05/pf/hsa-health-savings-account/index.html">the best tax-free investment account you’ll be able to find</a>.”</p>
<p>We know that American health care consumers are notoriously <a href="http://www.kff.org/health-reform/poll-finding/assessing-americans-familiarity-with-health-insurance-terms-and-concepts/">bad at understanding the U.S. insurance and health care system</a>. They also have <a href="http://www.annualreviews.org/doi/abs/10.1146/annurev-publhealth-082313-115826">problems understanding provider quality</a>. Shopping around, already challenging in the health care field – in case of an emergency or when there is only a limited number of providers – is hardly possible in these conditions.</p>
<h2>The recent Senate bill</h2>
<p>The most recent revision of the Senate’s Better Care Reconciliation Act makes four significant changes to HSAs and HDHPs.</p>
<p>First, it almost doubles the amount individuals are allowed to contribute, to $6,550 and $13,100 for individuals and families, respectively.</p>
<p>Second, it further increases these limits for Americans 55 and older in order to allow them to prepare for retirement.</p>
<p>Third, it also reduces the penalty individuals incur for withdrawing funds from their HSAs for nonqualified expenditures.</p>
<p>Fourth, and this is a significant departure from federal policy since the 1940s, it allows individuals and families to use money in HSAs to pay for insurance premiums. Previously, only individuals with employer-provided insurance were subject to preferential tax treatment.</p>
<h2>The rich can get richer?</h2>
<p><a href="http://www.washingtonexaminer.com/new-senate-republican-healthcare-plan-leaves-taxes-on-the-wealthy-in-place-lets-people-buy-less-expensive-plans/article/2628509">Under criticism from advocates and even members of his own party</a>, Senate Majority Leader Mitch McConnell’s (R-KY) most recently released Senate repeal-and-replace effort maintained many of the Affordable Care Act’s taxes. However, well-to-do Americans may have obtained an even better replacement in the form of Health Savings Accounts. We should also not forget that these taxes could be subject to repeal during the upcoming efforts at tax reform or the budget process.</p>
<p>We know very little about the long-term effects of high-deductible plans. However, <a href="http://content.healthaffairs.org/content/31/12/2641.full.pdf+html">scholarly findings</a> on delayed care, reduced preventive care and avoidance of medical care are cause for concern with potentially significant detrimental effects for the American health care system and Americans.</p>
<p>We also know that these arrangements further <a href="https://www.cbpp.org/research/gao-study-confirms-health-savings-accounts-primarily-benefit-high-income-individuals">segregate the risk pool and divide Americans based on their income and health status</a>. Richer and healthier individuals will seek out these plans to shelter their assets. Poorer and sicker Americans will not be able to reap these benefits.</p>
<p>More than 50 years ago, Nobel Prize-winning economist Kenneth Arrow prominently <a href="https://web.stanford.edu/%7Ejay/health_class/Readings/Lecture01/arrow.pdf">pointed out</a> that the health care field is filled with striking market failures. While HSAs and HDHP may sound like a good solution, they are unlikely, I would argue, to be viable and equitable solutions to what ails the American health care system.</p><img src="https://counter.theconversation.com/content/81013/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The latest Senate health care bill is still a hodgepodge of efforts to repeal Obamacare, critics say. One of their concerns is the focus on HSAs.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/759062017-04-24T23:24:24Z2017-04-24T23:24:24ZWhat the Trump team should consider before axing Meals on Wheels funds<p>To justify President Donald Trump’s aim to spend less on social services, Office of Management and Budget Director <a href="https://www.businessinsider.com.au/trump-budget-meals-on-wheels-funding-2017-3?r=US&IR=T">Mick Mulvaney declared</a>, “We can’t spend money on programs just because they sound good.” Who can argue with that? </p>
<p>Not us.</p>
<p>Like anyone else, we want our taxpayer dollars spent wisely. Funding programs that “sound good” but don’t accomplish much seems foolish. Still, this principle is way too broad to apply to complicated budget decisions. Our research suggests that identifying the best spending choices is a lot harder than it sounds. </p>
<h2>Assessing social service programs</h2>
<p>Mulvaney brought up <a href="http://www.mealsonwheelsamerica.org/">Meals on Wheels</a>, a program that delivers meals to 2.4 million homebound seniors a year, while trying to give a good example of something funded through the Community Development Block Grant program that Trump is seeking to eliminate altogether. The grants “were just not showing any results,” <a href="https://www.whitehouse.gov/the-press-office/2017/03/16/press-briefing-press-secretary-sean-spicer-3162017-25">he said</a> in mid-March.</p>
<p>The federal government <a href="http://origin-nyi.thehill.com/blogs/pundits-blog/economy-budget/324211-how-trumps-budget-cuts-could-affect-housing-for-thousands">spends about US$3 billion</a> annually on block-grant funds that states, counties and cities use to meet local needs as they see fit. This money helps make housing more affordable for low-income people, subsidizes child care and, in many communities, covers part of the cost of Meals on Wheels and other programs serving the elderly. </p>
<p>As public administration professors, we have studied how social service programs get assessed. In our <a href="http://www.tandfonline.com/doi/abs/10.2753/PMR1530-9576360101">research</a> at Binghamton University, we have surveyed and interviewed funders as well as providers of these programs to learn how they measure results and how they use that information once they get it. We found that each defines results in different ways and uses them in different ways, making it hard to prove whether government funded programs like Meals on Wheels “work.”</p>
<p>In one study, for example, we asked 20 funders and 20 providers the open-ended question, “Why do you collect performance information?” In a number of cases, interviewees provided more than one response.</p>
<p>What <a href="http://journals.sagepub.com/doi/full/10.1177/0899764014564578">we learned</a> is that providers often are more interested in improving their programs and becoming more responsive to the people who benefit from them. Funders such as the federal government, on the other hand, tend to prioritize making sure that the programs have the intended outcomes. </p>
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<p>However, there are risks to placing so much emphasis on results. This mindset can lead policymakers to a binary choice: Programs work or they don’t. Fund them if they do and defund them if they don’t.</p>
<p>To further complicate matters, social service organizations like Meals on Wheels must provide different kinds of performance-related information to each funder that supports them. Imagine the challenge, let alone confusion, these requirements create. For any one program, there is no single desired result. Each funder can judge a program’s success based on its own standard. </p>
<h2>Meals on Wheels</h2>
<p>Research about Meals on Wheels’ benefits supports our point. Should it improve nutrition? Provide companionship? Enable seniors to remain in their homes? Reduce health care costs? Without agreement on this program’s goals, there’s no single way to evaluate its results. </p>
<p>Mulvaney, for example, may care about one kind of result and the senior eating a delivered meal could care about another. The volunteer who delivered it and the local entity that handled the meal’s logistics might value yet other priorities. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/166160/original/file-20170420-20078-2gpj31.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/166160/original/file-20170420-20078-2gpj31.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=901&fit=crop&dpr=1 600w, https://images.theconversation.com/files/166160/original/file-20170420-20078-2gpj31.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=901&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/166160/original/file-20170420-20078-2gpj31.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=901&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/166160/original/file-20170420-20078-2gpj31.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1133&fit=crop&dpr=1 754w, https://images.theconversation.com/files/166160/original/file-20170420-20078-2gpj31.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1133&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/166160/original/file-20170420-20078-2gpj31.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1133&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Meals on Wheels deliveries can help seniors remain at home.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/breadfortheworld/22308168625/in/album-72157659653884569/">Bread for the World/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Since the budget director made this assertion, <a href="https://www.nytimes.com/2017/03/17/us/politics/fact-check-mick-mulvaney-trump-budget-director.html?ref=politics">reporters</a> and <a href="https://www.washingtonpost.com/opinions/mr-president-come-take-a-ride-with-meals-on-wheels/2017/04/07/1e8173d0-1893-11e7-9887-1a5314b56a08_story.html?utm_term=.4f9c8cb42160">op-ed writers</a> have countered what Mulvaney said about Meals on Wheels, citing studies about the program’s effectiveness. Brown University professors Kali Thomas and Vincent Mor, for instance, found that a mere one percent increase in the number of adults over age 65 receiving home-based meals could save Medicaid <a href="https://doi.org/10.1377/hlthaff.2013.0390">$109 million annually</a> by making it easier for the elderly to age in place. </p>
<p>Other studies find that having volunteers visit the home-bound makes them less lonely, less likely to suffer falls and less prone to depression – positive outcomes that trim health care costs. If Meals on Wheels generates these benefits, why cut spending on it?</p>
<p>Troublingly, if the government scraps Meals on Wheels or other programs, there may not be a replacement. If that happens, the problems the program addresses persist but there’s no longer a plan to address them. Isn’t improving programs a better option?</p>
<p>Social service providers are on the ground and mission-driven. Results matter to them, but not as ends in themselves. Instead, they are motivated to learn how to make good programs more effective and more responsive to the people they serve. Yes, funders must worry about results, but in many cases, they should use them to learn how to improve programs, not as an excuse to end them. </p>
<h2>Budgetary confusion</h2>
<p>Since Meals on Wheels gets far more federal cash from the Department of Health and Human Services than from block grants, it’s unclear whether the program is in jeopardy even if Congress backs Trump’s plan to scrap the <a href="https://nextcity.org/daily/entry/trump-budget-community-development-block-grants-cdbg-cuts">Community Development Block Grant</a> and the <a href="https://www.acf.hhs.gov/ocs/resource/csgg-fact-sheet">Community Services Block Grant</a> programs. </p>
<p>But the underlying issue remains: Mulvaney seemed to assume that everyone agrees what it means to say that Meals on Wheels does or does not work, that he’s looked into the matter and has decided that the program doesn’t work. His confusing comments raised a question at the heart of our research. What does it mean when someone claims a program “doesn’t work”?</p>
<p>Certainly, tax dollars should pay only for programs that work. But that principle is meaningless without context. To learn what works, these programs need clear goals recognized by all stakeholders. While some government-funded programs may not work, Mulvaney and the rest of the Trump administration should provide compelling evidence before defunding programs.</p><img src="https://counter.theconversation.com/content/75906/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nothing to disclose.</span></em></p><p class="fine-print"><em><span>David Campbell does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Trump’s budget director singled out Meals on Wheels as a waste of federal dollars. But identifying bad ways to spend taxpayer money is harder than it sounds.David Campbell, Associate Professor of Public Administration, Binghamton University, State University of New YorkKristina Marty, Associate Dean of the College of Community and Public Affairs, and an Associate Professor of Public Administration, Binghamton University, State University of New YorkLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/743982017-03-12T19:13:47Z2017-03-12T19:13:47ZThe House health plan: Here’s how the numbers don’t add up for the poor<figure><img src="https://images.theconversation.com/files/160366/original/image-20170310-19247-138a875.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Melva Watt, right, senior Medicaid interviewer, assists a patient with her application for Medicaid through the New York State Marketplace.
</span> <span class="attribution"><span class="source">Julie Jacobson/AP</span></span></figcaption></figure><p>House Republicans <a href="http://healthaffairs.org/blog/2017/03/07/examining-the-house-republican-aca-repeal-and-replace-legislation/">introduced the American Health Care Act</a> (AHCA), their proposal to repeal and replace the Affordable Care Act (ACA, also known as Obamacare). </p>
<p>At a press conference, Speaker Paul Ryan called this bill “<a href="http://www.usatoday.com/videos/news/nation/2017/03/07/paul-ryan-health-care-reform-'act-mercy'/98878852/">an act of mercy</a>.” For the most vulnerable, that characterization is ironic at best.</p>
<p>Yes, there are winners in this bill. But those who benefit would be predominantly young, healthy and less likely to need insurance or older, well off and more likely to be able to afford insurance. </p>
<p>The potential effects of this bill on certain segments of the population are clear: For the <a href="https://www.cdc.gov/pcd/issues/2014/13_0389.htm">millions of Americans with multiple chronic conditions</a>, and for <a href="https://www.ssa.gov/cgi-bin/netcomp.cgi?year=2015">nearly 100 million Americans</a> who earn less than US$40,000 a year, AHCA would bring less coverage and higher costs than under the ACA.</p>
<h2>A quick review</h2>
<p>First, it’s important to understand how much the ACA has helped Americans afford health insurance coverage. In 2009, <a href="https://factfinder.census.gov/bkmk/table/1.0/en/ACS/09_1YR/S2701">15.1 percent</a> of Americans were uninsured. By 2015, that number had fallen to <a href="https://factfinder.census.gov/bkmk/table/1.0/en/ACS/15_1YR/S2701">9.4 percent</a>. </p>
<p>Those who gained coverage did so primarily through the expansion of Medicaid and through the ACA’s health insurance marketplace. These coverage expansions have provided crucial assistance to low-income Americans, many of whom were unable to afford coverage before the ACA.</p>
<p>Today, adults with incomes up to 138 percent of the federal poverty level, or about $16,394 in 2017, are eligible to enroll in Medicaid in the 32 states, including the District of Columbia, that expanded the program. </p>
<p>The law had originally intended for all states to expand their Medicaid programs; a 2012 Supreme Court ruling made the expansion a state option. People with incomes up to 400 percent of the federal poverty level, or $47,520 in 2017, can get financial assistance to purchase coverage on the Health Insurance Marketplace.</p>
<p>In 2016, nearly <a href="https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-06-30.html">9.4 million people</a> – 85 percent of Health Insurance Marketplace enrollees – received tax credits to help pay for premiums. </p>
<p>In addition, under the ACA, individuals with incomes less than 250 percent of the federal poverty level, or $29,700 in 2017, receive cost-sharing reduction subsidies to help pay for copays and deductibles. </p>
<p>Almost <a href="https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-06-30.html">6.4 million people</a> – 57 percent of 2016 Health Insurance Marketplace enrollees – received these subsidies to help lower their out-of-pocket costs. The cost-sharing subsidies helped people to afford health care as well as insurance coverage.</p>
<h2>Presidential promises for insurance for everyone – and cheaper</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/160369/original/image-20170310-19226-n9e4uh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/160369/original/image-20170310-19226-n9e4uh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/160369/original/image-20170310-19226-n9e4uh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/160369/original/image-20170310-19226-n9e4uh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/160369/original/image-20170310-19226-n9e4uh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/160369/original/image-20170310-19226-n9e4uh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/160369/original/image-20170310-19226-n9e4uh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">President Donald Trump speaks in the Roosevelt Room of the White House in Washington, Friday, March 10, 2017, during a meeting on health care.</span>
<span class="attribution"><span class="source">Evan Vucci/AP</span></span>
</figcaption>
</figure>
<p>Over the past several months, President Trump has <a href="https://www.washingtonpost.com/politics/trump-vows-insurance-for-everybody-in-obamacare-replacement-plan/2017/01/15/5f2b1e18-db5d-11e6-ad42-f3375f271c9c_story.html?tid=ss_tw&utm_term=.65c62a393e38">promised</a> an ACA replacement plan that will provide “insurance for everybody” that is “much less expensive and much better” with “much lower deductibles.” </p>
<p>Those promises are good benchmarks to help us evaluate the impact of the American Health Care Act. </p>
<p>In its current form, the AHCA simply does not accomplish any of those goals for people with low incomes, people over 60, or people who live in areas where health care costs are high, such as rural areas. Indeed, the AHCA may end up putting health coverage out of reach for many of those who gained it under the ACA.</p>
<p>The AHCA replaces the ACA’s income-based premium tax credits with age-adjusted tax credits (with an income limit of $115,000). Under the AHCA, adults in their 20’s would receive a $2,000 annual tax credit to help purchase individual market coverage, with tax credits increasing up to $4,000 for a 60-year-old. </p>
<p>These proposed tax credits <a href="http://healthaffairs.org/blog/2017/03/07/examining-the-house-republican-aca-repeal-and-replace-legislation/">do not take into account</a> an individual’s income or the price of health insurance in their area, as the ACA did. According to the <a href="http://kff.org/health-reform/issue-brief/how-affordable-care-act-repeal-and-replace-plans-might-shift-health-insurance-tax-credits/">Kaiser Family Foundation</a>, the average annual premium tax credit in 2017 under the ACA for a 60-year-old making $20,000 a year was $9,874.</p>
<p>Under the AHCA, that same 60-year-old would receive <a href="http://kff.org/health-reform/issue-brief/how-affordable-care-act-repeal-and-replace-plans-might-shift-health-insurance-tax-credits/">less than half</a> that amount, according to an analysis by the Kaiser Family Foundation. In many areas of the United States, particularly rural areas, older Americans would receive <a href="https://www.nytimes.com/interactive/2017/03/08/upshot/who-wins-and-who-loses-under-republicans-health-care-plan.html">significantly less financial assistance</a> to help pay for premiums than they currently receive.</p>
<p>Under the ACA, the premium tax credit amount that enrollees may receive is based on two key factors: the local benchmark premium cost and the enrollee’s household income. Under the AHCA, premium tax credits would be based only on age and would not be tailored to local costs.
The AHCA would also repeal the ACA’s cost-sharing subsidies in 2020, putting care even further out of reach for many.</p>
<p>The AHCA would expand those age bands so that older adults could now be charged up to five times higher premiums than their younger counterparts. Older adults could not only see a decrease in financial assistance to pay for premiums, but their premiums could increase as well.</p>
<h2>More to the problem than Medicaid loss</h2>
<p>For the <a href="http://www.modernhealthcare.com/article/20161109/NEWS/161109895">12 million people</a> who are now covered through Medicaid expansion, the outlook is equally gloomy. The AHCA would freeze Medicaid expansion beginning in 2020. States that had already expanded the program would continue to receive enhanced federal funding for current enrollees who remain on the program. </p>
<p>But states would receive far less federal funding to cover any new enrollees or any existing enrollee who experiences a lapse in coverage longer than one month. Many states would find it difficult to continue Medicaid expansion under these circumstances.</p>
<p>In addition, beginning in 2020, the bill would shift Medicaid to a per-capita cap. This would be a fundamental restructuring of the Medicaid program, affecting over <a href="http://kff.org/health-reform/state-indicator/total-monthly-medicaid-and-chip-enrollment/?currentTimeframe=0&selectedRows=%7B%22wrapups%22:%7B%22united-states%22:%7B%7D%7D%7D">70 million people</a>. </p>
<p>Unlike today, where the federal government guarantees it will match states’ costs to provide care to Medicaid beneficiaries, a per-capita cap would give states a fixed amount of money per enrollee. The state would be responsible for any expenses beyond that amount. </p>
<p>According to the <a href="http://www.cbpp.org/medicaid-cost-shifts-in-house-gop-plan-would-total-an-estimated-370-billion-over-10-years-and-grow">Center for Budget and Policy Priorities</a>, the AHCA’s proposed Medicaid changes would shift $370 billion in costs to states over 10 years. As a result, states would try to contain costs by curtailing benefits or limiting enrollment in their Medicaid programs – not just in the expansion population, but across the board. </p>
<p>While House Republicans claim these changes will grant more flexibility to states to make innovations in their Medicaid programs, the proposed structure would likely end up cutting benefits for millions of adults and children as states scramble to fill the shortfall from fewer federal Medicaid dollars.</p>
<p>Perhaps the AHCA can improve coverage and lower costs, but the real question is: For whom? </p>
<p>For the young, healthy, and high-income earners, quite possibly. But for lower-income individuals, older adults, people living in rural areas and people who gained Medicaid coverage under the ACA, it seems unlikely that the AHCA is anything but a bad deal.</p><img src="https://counter.theconversation.com/content/74398/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Megan Foster Friedman does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>House Speaker Paul Ryan called the new health care proposal an ‘act of mercy.’ The bill could help the healthy and wealthy, but it is unlikely to be merciful to the poor.Megan Foster Friedman, Health Policy Analyst, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/713032017-02-13T01:51:27Z2017-02-13T01:51:27ZTrump wants to change Medicaid funding; could his ideas work?<p>Medicaid, which has provided safety net health care for millions of Americans with low incomes <a href="https://www.cms.gov/About-CMS/Agency-Information/History/index.html">since 1965</a>, pays for medical care for about <a href="http://kff.org/health-reform/slide/current-status-of-the-medicaid-expansion-decision/">75 million people in the U.S.</a>, including almost two-thirds of those in nursing homes. </p>
<p>You likely know someone who benefits from Medicaid. It could be someone whose nursing home care is paid by Medicaid, even if that person at one time had retirement savings, a home and a good income. The costs of long-term care are such that, if a person was not poor when he or she became disabled or old, there’s a good chance that he or she will soon become poor. Medicaid pays for about <a href="http://kff.org/report-section/medicaid-financial-eligibility-for-seniors-and-people-with-disabilities-in-2015-report/">six million people</a> in nursing homes. </p>
<p>Medicaid also pays for medical care for about <a href="http://kff.org/report-section/medicaid-financial-eligibility-for-seniors-and-people-with-disabilities-in-2015-report/">10 million children and adults</a>. You might know a young adult who is covered by Medicaid and who grew up with a diagnosis like cystic fibrosis or kidney disease that made it impossible to work as an adult. </p>
<p>Medicaid accounts for <a href="http://kff.org/health-reform/slide/current-status-of-the-medicaid-expansion-decision/">about 17 percent of the nation’s health care expenditures in 2015</a>. In 2015, the government spent about <a href="http://kff.org/medicaid/state-indicator/total-medicaid-spending/?currentTimeframe=0">US$532 billion</a> on the program. </p>
<p>President Trump and other GOP leaders not only want to repeal the ACA but also to change Medicaid’s funding mechanism to something called block grants. Trump believes the change will save the federal government billions of dollars, and that could be true. </p>
<p>A study presented Feb. 6 to Congress by Avalere Health, a D.C.-based health care consulting firm, forecast savings of <a href="http://thehill.com/policy/healthcare/318164-study-block-granting-medicaid-would-save-federal-government-150-billion">$150 billion by 2022.</a>
But a switch to block grants could also leave millions of poor people without insurance, or it could lead to cutbacks in services they receive.</p>
<p>As a social worker and instructor who has worked with and taught about Medicaid and other health policy systems including block grants over the past 25 years, I can say that going to block grants for Medicaid will represent a disruptive change. Looking at how block grants have affected a long-standing poverty alleviation program shows that there is some risk involved. </p>
<h2>Block grants 101</h2>
<p>Block granting is a structure of federal funding in which a set sum of money is allocated to states within a period of time, for use in the way the states see fit to meet a specified need.</p>
<p>Block grant funding for Medicaid would differ significantly from how Medicaid is funded now. For the most part, Medicaid now operates as either a negotiated fee-for-service system or a monthly rate per Medicaid enrollee. The federal government pays a portion of the expenses, and <a href="https://www.medicaid.gov/medicaid/financing-and-reimbursement/index.html">state government pays the other portion</a>.</p>
<p>Many in the GOP support the block grant plan, citing block grant funding that has been used for <a href="http://apps.washingtonpost.com/g/page/politics/read-the-house-gops-poverty-report/850/">Temporary Assistance to Needy Families</a> (TANF). In the TANF program, states are allocated an established amount of funding to “to help needy families <a href="https://www.acf.hhs.gov/ofa/programs/tanf/about">achieve self-sufficiency</a>.” States design and implement programs, with minimal federal guidelines, to achieve their TANF goals. </p>
<p>Some states spend more funding on basic assistance and work supports, while other states spend more funding on child care and tax credits for <a href="http://www.cbpp.org/research/family-income-support/how-states-use-funds-under-the-tanf-block-grant">working families with low incomes</a>. </p>
<p>Some see the variation in the use of funds as a strength while others see it as ineffective. The 2014 <a href="http://apps.washingtonpost.com/g/page/politics/read-the-house-gops-poverty-report/850/">GOP House report</a> indicated TANF “is widely seen as the most successful reform of a welfare program.”</p>
<p>Depending on how you view the numbers, that could be true.</p>
<p>Caseload <a href="http://apps.washingtonpost.com/g/page/politics/read-the-house-gops-poverty-report/850/">levels for cash assistance fell</a> from 5.1 million households in the 1980s to 1.9 million households in 2010. Some point to those numbers as evidence of fewer families living in poverty. </p>
<h2>Block grants 102</h2>
<p>There’s more to that story, however. Others see TANF as a failure, and they cite the structure of TANF as a <a href="http://www.cbpp.org/research/family-income-support/how-states-use-funds-under-the-tanf-block-grant">block grant as the cause</a>.</p>
<p>Viewing the <a href="http://www.cbpp.org/research/tanf-weakening-as-a-safety-net-for-poor-families">lower TANF caseloads as evidence of less need or poverty</a> may not be accurate, because TANF caseloads continued to decline even in times of recession when poverty levels increased.</p>
<p>Thus, lower TANF caseloads may not actually be tied to less need but instead to families being unable to receive benefits due to changes in TANF structure. </p>
<p>It’s hard to know for certain whether the switch to block grants is responsible, but the rate of potentially eligible TANF recipients receiving TANF assistance has fallen from <a href="https://www.acf.hhs.gov/sites/default/files/opre/change_time_1.pdf">86 percent in 1992 to 36 percent in 2007</a>. Meanwhile, the <a href="http://nlihc.org/article/welfare-reform-increased-deep-poverty-among-children">number of children living in deep poverty</a> (income less than 50 percent of the federal poverty level) in the U.S. has risen from 1.5 to 2.2 million between 1995 and 2005. </p>
<p>Those families living in deep poverty <a href="http://www.cbpp.org/research/family-income-support/chart-book-tanf-at-20">are now less able to count on TANF </a>for assistance like they did in 1995. Then, 61 percent of children living in poverty would have been in deep poverty without TANF assistance. More recently, only 24 percent of children living in poverty would be in deep poverty without TANF assistance, making it appear that TANF is no longer serving the families with the most need.</p>
<h2>When budget shortfalls occur, block grant money looks tasty</h2>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/156092/original/image-20170208-17345-1l1x11i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/156092/original/image-20170208-17345-1l1x11i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=494&fit=crop&dpr=1 600w, https://images.theconversation.com/files/156092/original/image-20170208-17345-1l1x11i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=494&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/156092/original/image-20170208-17345-1l1x11i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=494&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/156092/original/image-20170208-17345-1l1x11i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=620&fit=crop&dpr=1 754w, https://images.theconversation.com/files/156092/original/image-20170208-17345-1l1x11i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=620&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/156092/original/image-20170208-17345-1l1x11i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=620&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Preschoolers painting.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/572584078?size=huge_jpg">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>And, many who view TANF as a failure blame the block grant system, precisely because states have leeway to use TANF funding according to what they deem most appropriate. States have <a href="http://www.cbpp.org/research/family-income-support/how-states-use-funds-under-the-tanf-block-grant">shifted away</a> from spending the majority of their allocated funding on the core functions of TANF, including basic assistance, child care and work-related supports. </p>
<p>Instead, they spend money in areas such as child welfare/protective services and and pre-K programs, which are normally funded by states. In essence, the states use their federal dollars for budget shortfalls in other areas.</p>
<p>These services, while important, are not included in the core functions of the TANF program. States are spending about half of TANF funds <a href="http://www.cbpp.org/research/family-income-support/how-states-use-funds-under-the-tanf-block-grant">outside the core function areas </a>.</p>
<p>For example, <a href="http://www.cbpp.org/research/family-income-support/how-states-use-funds-under-the-tanf-block-grant">Texas spent 38 percent of TANF funds</a> on Pre-k and Early Headstart in 2015. <a href="http://www.cbpp.org/research/family-income-support/how-states-use-funds-under-the-tanf-block-grant">Half of TANF funds in Georgia were spent </a>on child welfare/protective services in the same year. </p>
<p>In addition to the issues with usage of federal dollars, the federal TANF block grant funding <a href="http://www.cbpp.org/research/family-income-support/how-states-use-funds-under-the-tanf-block-grant">does not include an adjustment for inflation</a>, so it has lost one-third of its value since 1997. States are now being asked to provide TANF services with less funding. </p>
<h2>Applying lessons learned to Medicaid</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/156090/original/image-20170208-17337-1or7sem.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/156090/original/image-20170208-17337-1or7sem.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/156090/original/image-20170208-17337-1or7sem.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/156090/original/image-20170208-17337-1or7sem.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/156090/original/image-20170208-17337-1or7sem.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/156090/original/image-20170208-17337-1or7sem.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/156090/original/image-20170208-17337-1or7sem.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Trump moved swiftly to try to repeal Obamacare, signing an executive order his first day in office.</span>
<span class="attribution"><span class="source">Evan Vucci/AP.</span></span>
</figcaption>
</figure>
<p>Medicaid is a much larger program than TANF, and the effects could be much larger. About <a href="http://www.cbpp.org/research/health/policy-basics-introduction-to-medicaid">$476 billion was spent</a> on Medicaid services in 2014, meaning the financial risks are much higher depending on how states manage their block grant funds. </p>
<p>With the emphasis on more flexibility and less federal government oversight, the federal government could <a href="http://www.ncd.gov/publications/2013/05222013/">move away</a> from federal regulations for Medicaid and allow states to have the maximum control over service provision systems.</p>
<p>While this could lead to innovation, it could also put some vulnerable citizens at risk. The needs of the most vulnerable in health care coverage systems, the chronically ill, the disabled, the elderly, are <a href="http://www.cbpp.org/blog/why-rhode-islands-no-model-for-a-medicaid-block-grant">often the most expensive to meet</a>. States with the lowest budgets for health care to combine with federal block grant funding might experience <a href="http://www.cbpp.org/sites/default/files/atoms/files/5-3-11health.pdf">deep cuts in Medicaid services</a>, affecting the health of many.</p>
<h2>The poor could be very, very vulnerable</h2>
<p>There are few who question that the move to Medicaid block grants would save the federal government money. The federal government will save the most money by the establishment of Medicaid block grants that don’t fluctuate in funding levels <a href="http://www.cbpp.org/sites/default/files/atoms/files/5-3-11health.pdf">due to the economic environment or with greater demand</a>, like in an epidemic.</p>
<p>States, though, will have to either budget to plan for those circumstances or cut services when the need gets too high. It’s this last point that could create a shift in the fundamental ideology behind Medicaid as an entitlement program, which guarantees certain benefits to particular groups of people. </p>
<p>The transition of Medicaid to a block grant system may give so much flexibility to states and create a funding system so undependable in times of crisis that Medicaid can no longer be considered a true entitlement or a safety net. As with the TANF program, it will be the vulnerable who stand to lose the most.</p>
<p><em>This article was updated on Feb. 14 to indicate the figure regarding government spending on Medicaid includes federal and state money.</em></p><img src="https://counter.theconversation.com/content/71303/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Cossy Hough does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>President Trump has proposed a major funding shift for Medicaid, the joint federal-state program that pays for health care for about 75 million poor people. Would the safety net fray if he did so?Cossy Hough, Clinical Assistant Professor School of Social Work, The University of Texas at AustinLicensed as Creative Commons – attribution, no derivatives.