The Fund supports several networks of state health policymakers to help identify, inspire, and inform policy leaders.
The Milbank Memorial Fund supports two state leadership programs for legislative and executive branch state government officials committed to improving population health.
The Fund identifies and shares policy ideas and analysis on topics important to state health policymakers, particularly on issues related to state leadership, primary care, aging, and health care costs.
Keep up with news and updates from the Milbank Memorial Fund. And read the latest blogs from our thought leaders, including Fund President Christopher F. Koller.
The Fund publishes The Milbank Quarterly, as well as reports, issues briefs, and case studies on topics important to health policy leaders.
The Milbank Memorial Fund is is a nonpartisan foundation focused on improving the health of communities and entire populations.
Dec 23, 2021
Back to The Milbank Quarterly
As night follows day, the Trump administration and Congressional leaders have announced that they intend to use welfare reform to finance their historic tax legislation, estimated to cost the federal government some $1.5 trillion in lost revenue over the next decade (a figure that, according to experts, is a serious understatement), not to mention its spillover effects on state economies. Welfare reform, like its rhetorical sister entitlement reform, is nothing more than a euphemism for policies—that will find their voice in formal actions undertaken by both the legislative and executive branch—whose aim is to eviscerate government spending on programs that provide direct assistance to the nation’s poorest and most vulnerable populations.
By now we all have learned to decode the term “welfare reform.” In the coming months, we also will hear words like “innovation,” “efficiency,” and “state flexibility” until we are so sick of them we can barely think. And of course the favorite welfare trope of the moment—able-bodied adults—will be a dominant theme. The special language of one side’s view of welfare reform—hauled out whenever the subject turns to government assistance for the poor—is part of the political package deal on which the subject rests.
One might think that with the Alabama and Virginia election results fresh in everyone’s mind, and with the real possibility of a wave election in 2018, the White House and Congressional Republicans would adopt a more conciliatory posture. But this clearly is not the case: Welfare reform is high on the agenda. Rather than causing one to lift one’s foot from the throttle, an existential threat to power may have the opposite result, redoubling commitment to a cause as long as power lasts. This may especially be the case here, given what most observers anticipate will be tax reform’s long-term adverse impact to federal revenue and spending ability.
If public opinion polls are to be believed, the Republican party’s own political base pretty much understands how little it stands to gain under tax reform. But what these very same people probably don’t yet realize is what they stand to lose in the form of direct governmental assistance vital to family and community health. Decades of past welfare reform efforts—not to mention the total willingness on the part of the White House and Congressional leaders to let us know exactly what they mean when they talk of entitlement reform—allow us to know that we can expect an unremitting, vast legislative attack on government’s social safety net programs, which already experience a level of commitment well below that found in other wealthy nations.
We also can expect a blizzard of agency action—the attempt to use Presidential powers to the maximum degree possible—whose purpose is to bend the design and operation of public welfare programs to the administration’s will. The White House already signaled that major executive action on welfare reform is coming. Anticipate a lot of litigation as advocates for the poor and underserved seek the aid of the courts to stop an avalanche of regulatory policies—some that make the news and others that do not—from going into effect. Many of these efforts will buy time, perhaps, but ultimately will fail under a judiciary also being reshaped in this administration’s image.
Here are 4 programs to watch most closely; they are by no means the only ones, of course, but they are public benefit mainstays.
Temporary Aid to Needy Families (TANF). A program for which modesty is an understatement, providing essential and almost nonexistent aid to less than 1%of the population. One might not think that things could get much worse for children and parents who depend on TANF, the successor to Aid to Families With Dependent Children (AFDC), repealed and replaced in 1996. At its zenith, AFDC helped about 11 million children and their parents. In March 2017, TANF reached 2.5 million people—overwhelmingly children—ranging from about 900,000 in California to fewer than 700 in the US Virgin Islands.1 With TANF already time limited and filled with requirements designed to deny and exclude, how many fewer people can it be redesigned to reach? Apparently there is room, through additional sanctions and work requirements.
Supplemental Nutrition Assistance Program (SNAP). Perhaps the most important daily income supplementation program the government offers, with the power to lift millions out of poverty. As of August 2017, slightly more than 31 million people depended on SNAP to provide essential food assistance. Today about 44% of SNAP recipients live in households with at least one working family member and the average SNAP household receives about $254 per month in benefits.2 Work requirements are already a program feature for working-age adults. Expect these rules to tighten, along with other restrictions.
Social Security Disability Assistance (SSDI). A vital means of supporting workers whose disabilities prevent their continued workforce participation. Along with the Supplemental Security Income (SSI) program for the most impoverished people, SSDI is the means by which millions subsist. As of October 2017, about 8.7 million disabled workers received monthly checks.3 Their average monthly check in 2017 was about $1,170. Harsher measures of disability, time limits, and toughened work requirements all can be expected. Expect SSI for the disabled under-65 population also to be in the spotlight; in October 2017, slightly more than 5 million received subsistence benefits under this companion program.4
Medicaid. The big kahuna. The mother of all public health programs, with total federal and state expenditures projected to close in on nearly $1 trillion by 2025.5 Over 40% of beneficiaries are children; another 25% are elderly or persons with disabilities. Working-age adults without disabilities represent the remaining 35%. In a far-reaching attempt to pull the nation’s single largest insurer—70 million beneficiaries—back to its welfare roots, the Trump administration is actively encouraging states to pursue eligibility and enrollment restrictions, time limits, work requirements, and other strategies to cull the rolls. And of course from the Affordable Care Act repeal and replace effort, we already know what to expect from Congress: block grants calculated to move the government away from its historic commitment to the states where indigent health care is concerned, while saving trillions of dollars in federal outlays, culminating in an estimated one-third reduction in federal spending by 2036.
Knowing what is likely coming does not make things easier. It just heightens the tragic reality of how this administration and Congressional leadership plan to finance their tax cuts, secure in the belief that, even should they lose political control, the die has been cast for American social welfare policy. No matter what the size of the electoral wave that could materialize in 2018, it will be too late for these families and for US public policy.
Sara Rosenbaum is the Harold and Jane Hirsh Professor of Health Law and Policy and founding chair of the Department of Health Policy at the George Washington University School of Public Health and Health Services. She also holds professorships in the Schools of Law and Medicine and Health Sciences. A graduate of Wesleyan University and Boston University Law School, Rosenbaum has devoted her career to issues of health justice for populations who are medically underserved as a result of race, poverty, disability, or cultural exclusion. Between 1993 and 1994, Rosenbaum worked for President Clinton, where she directed the drafting of the Health Security Act and designed the Vaccines for Children program, which today provides near-universal immunization coverage to low-income and medically underserved children. Rosenbaum is the leading author of Law and the American Health Care System (Foundation Press, 2012) and has received many national awards for her work in public health policy. She is past chair of AcademyHealth and a member of the Institute of Medicine. Rosenbaum also has served on the CDC Director’s Advisory Committee and as a Commissioner on the Congressional Medicaid and CHIP Payment and Access Commission (MACPAC), which she chaired from January 2016 through the expiration of her term in April, 2017.
Get the Latest from the Milbank Memorial Fund
The Milbank Quarterly’s multidisciplinary approach and commitment to applying the best empirical research to practical policymaking offers in-depth assessments of the social, economic, political, historical, legal, and ethical dimensions of health and health care policy.