As the Senate takes up health care reform, it is important to highlight the ways in which the Affordable Care Act differs from unpopular welfare programs. Republican politicians are using the health care debates as an opportunity to continue their long war against the poor, but what worked when attacking welfare is unlikely to play equally well when it comes to health care. Even though the suggestion by Rep. Jason Chaffetz (R-Utah) that the poor could afford health care if they forgo a new iPhone is ridiculous, it taps into a long-standing line of argument that the poor have too much stuff and therefore should not get assistance. Ronald Reagan rode the welfare queen’s Cadillac all the way to the White House and the Heritage Foundation’s Robert Rector has almost made a career out of counting the number of poor households that have things like air conditioning, cable television, and refrigerators. Rep. Roger Marshall (R-Kan.)’s equally laughable statement that the poor “just don’t want health care” also reflects this conservative line-of-attack. In this imagined view of poverty, the poor have resources but they make bad choices and therefore should not get state assistance.
The attack the poor strategy worked with welfare reform and was embraced by President Clinton as part of his strategy of triangulation, which involved moving the Democratic Party close to the "political center." In many ways, the Paul Ryan and Donald Trump reworking of U.S. health care is based on the welfare reform playbook. Welfare reform’s main goal was to bury the idea that people had a right to welfare that had gained limited traction before the courts and that, the argument went, had become a way of life for too many people. Euphemistically titled the Personal Responsibility and Work Opportunity Act, welfare reform accomplished this goal by imposing work requirements on recipients, putting making individual eligibility to welfare subject to a five-year-lifetime time limit, and moving from a federal program to a federalism-based block grant to states. Rhetorically at least, block grants allow states with more freedom to design their own programs and figure out what works best for the poor in their state. They could, for example, theoretically decide to use some of the money to support additional childcare options or transportation access for the working poor. In practice, states clamped down on welfare, making it hard for the poor to get assistance and easy for them to lose eligibility. Doing so allowed states to reduce the welfare rolls and use a large percentage of the federal block grant to fill unrelated state budget holes, diverting money meant to help the poor to general funds.
Welfare reform “succeeded”—and is acknowledged as a success not only by Republicans but also by Democratic centrists—in dramatically reducing the welfare rolls. Driven by the work and time limits coupled with the strong economy of the late 1990s, welfare recipients, especially single mothers, joined the workforce. The House version of health care reform passed on May 4th seeks to build on this success story and, similar to welfare reform, relies heavily on the rhetoric of federalism to move away from the emerging right to health care coverage promised by Obamacare. The Affordable Care Act does not actually provide universal coverage, but it moved the country in that direction. Republicans hope that by making the health care debate about what is wrong with poor people they can prevent health care from being recognized as a right and divert attention from the significant regressive wealth transfers contained in this latest salvo in their war against the poor.
Unfortunately for Republicans, health coverage and cash assistance are not the same. Members of the middle class, even if they have coverage, are vulnerable to financial ruin resulting from a single health crisis. Losing a job means an entire family, including any children, can no longer get the same employer-provided coverage. Put differently, while the poor could be demonized and treated as “other”—on both moral and, implicitly, racial grounds—when it came to cash assistance, middle class claims to health care are not far removed from similar claims by the poor. The overlapping interests will make it harder for Republicans to label their version of health care reform a “success.” The great recession of 2008 helped reveal the downside of welfare reform that had previously been hidden by economic growth and a tight labor market: far too many Americans are living in extreme poverty. Many of the extremely poor live on food stamps alone. The food stamp program (SNAP) provided a needed but inadequate social safety net for poor families: when the economy went south, food stamp enrollment rose. This is true in part because SNAP remains a federal program at least for the moment, though House Speaker Paul Ryan (R.-Wis) wants to convert it to a block grant as well. Welfare, in contrast, did not respond to economic downturn in the same way; instead, it continued to “succeed” in keeping people off the welfare rolls.
Though lowering the number of people on welfare was enough for the public to accept that welfare reform succeeded, it is much harder to claim that millions of people losing their health care will Make America Great Again. Americans of all economic classes, though they largely accept welfare reform rhetoric regarding cash assistance, are not likely to be so quick to accept the same narrow definition of “success” when it comes to health care and therefore it is hard for Republicans to convert health care reform into a “win.” Hopefully the Senate will recognize this, even though Ryan managed to squeeze health reform through the House.