“After a few months in the program, Smith was no longer diabetic, and she has now been sober for two and a half years.
Her story highlights the success of the Healthy Opportunities Pilot, which launched in North Carolina in March 2022. The program had benefits beyond health and quality-of-life improvements; researchers at UNC-Chapel Hill found the program saved $1,020 a year per recipient on health care costs, and the 38,000 participants had “significantly lower” emergency room visits than their peers.
The program was unique, funded with a five-year, $650 million federal grant approved by the first Donald Trump administration. The idea was to use fresh food, safe housing and transportation — social and economic factors that researchers say determine 80 percent of a person’s health — to improve the lives of the sickest, most expensive patients.
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But the Healthy Opportunities Pilot shows the limits of such food-based interventions in public policy. These programs often require longer-term investments, chafing against the cost-cutting instincts that characterize Trump’s second term and legislatures in most red states — the policy level at which most MAHA ideas are put into practice.
In the case of HOP, the Joe Biden administration approved a Medicaid waiver last December to continue the program in North Carolina, which Gov. Josh Stein, a Democrat, hoped to expand throughout the state over the next two years. But in June, the Republican-led state legislature declined to fund it. State lawmakers argue the program costs more than it saves — a claim that state policy experts dispute because of the way Republican lawmakers were calculating the numbers. These experts say the long-term savings potential was given short shrift.”
“The poorest 10% of households will lose an average of about $1,200 in resources per year, amounting to a 3.1% cut in their income, according to the analysis released Monday of the “One Big Beautiful Bill Act.” Households in the highest 10% of incomes will see about a $13,600 boost in resources on average, amounting to a 2.7% increase in their incomes.
Earners in the middle of the distribution will see their annual resources grow by about $800 to $1,200 on average, according to the analysis.”
“Most Medicaid recipients (92 percent) under the age of 65 already work full- or part-time jobs, according to KFF.”
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“States have attempted to implement work requirements for their Medicaid programs, but have faced challenges to successful implementation. In 2018, when Arkansas attempted to implement similar Medicaid work requirements, confusion with paperwork resulted in 18,000 people losing health care, and there was no improvement in employment rates. Georgia’s work requirement program, which began in 2023, spent $55 million verifying eligibility. It enrolled only 2.3 percent of the estimated 240,000 Georgians who were eligible for the program.”
“Several former Republican governors in the Senate have sounded alarms over a controversial House GOP plan to help pay for the Trump megabill by pushing billions in federal food aid costs to states.
Now there’s a would-be governor raising similar concerns. Behind the scenes in recent days, Sen. Tommy Tuberville of Alabama raised issues over the provision with GOP leaders and pushed for the plan to be scaled back, according to three Republicans granted anonymity to describe the conversations.”
“In an ideal world, everyone who qualifies for an aid program ought to receive its benefits. But the reality is that this is often not the case. Before the pandemic, for example, nearly one-fifth of Americans who qualified for food stamps didn’t receive them. In fact, millions of Americans who are eligible for existing social welfare programs don’t receive all of the benefits they are entitled to.”
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“Means testing a given social program can have good intentions: Target spending toward the people who need it most. After all, if middle- or high-income people who can afford their groceries or rent get federal assistance in paying for those things, then wouldn’t there be less money to go around for the people who actually need it?
The answer isn’t so straightforward.”
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“Implementing strict eligibility requirements can be extremely tedious and have unintended consequences.
For starters, let’s look at one of the main reasons lawmakers advocate for means testing: saving taxpayers’ money. But that’s not always what happens. “Though they’re usually framed as ways of curbing government spending, means-tested benefits are often more expensive to provide, on average, than universal benefits, simply because of the administrative support needed to vet and process applicants,” my colleague Li Zhou wrote in 2021.
More than that, means testing reduces how effective antipoverty programs can be because a lot of people miss out on benefits. As Zhou points out, figuring out who qualifies for welfare takes a lot of work, both from the government and potential recipients who have to fill out onerous applications. The paperwork can be daunting and can discourage people from applying. It can also result in errors or delays that would easily be avoided if a program is universal.
There’s also the fact that creating an income threshold creates incentives for people to avoid advancing in their careers or take a higher-paying job. One woman I interviewed a few years ago, for example, told me that after she started a job as a medical assistant and lost access to benefits like food stamps, it became harder to make ends meet for her and her daughter. When lawmakers aggressively means test programs, people like her are often left behind, making it harder to transition out of poverty.
As a result, means testing can seriously limit a welfare program’s potential. According to a report by the Urban Institute, for example, the United States can reduce poverty by more than 30 percent just by ensuring that everyone who is eligible for an existing program receives its benefits. One way to do that is for lawmakers to make more welfare programs universal instead of means-tested.”
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“There sometimes is an aversion to universal programs because they’re viewed as unnecessarily expensive. But universal programs are often the better choice because of one very simple fact: They are generally much easier and less expensive to administer. Two examples of this are some of the most popular social programs in the country: Social Security and Medicare.
Universal programs might also create less division among taxpayers as to how their money ought to be spent. A lot of opposition to welfare programs comes from the fact that some people simply don’t want to pay for programs they don’t directly benefit from, so eliminating that as a factor can create more support for a given program.
In 2023, following a handful of other states, Minnesota implemented a universal school meal program where all students get free meals. This was in response to the problems that arise when means testing goes too far. Across the country, students in public school pay for their meals depending on their family’s income. But this system has stigmatized students who get a free meal. According to one study, 42 percent of eligible families reported that their kids are less likely to eat their school meal because of the stigma around it.
Minnesota’s program has proven popular so far: In September 2023, shortly after the program took off, the amount of school breakfasts and lunches served increased by 30 percent and 11 percent compared to the previous year, respectively.
While it might not be politically feasible — or, in some cases, necessary — to get rid of means testing for all public subsidies, free school meals also offer an example of what a compromise might look like at the national level. Though Congress hasn’t made school meals free to all, it passed a provision in 2010 that allows schools to provide free meals to all students in districts where at least 25 percent (originally 40 percent) are eligible. The program showed that providing free meals to all lowered food insecurity, even among poor students who already qualified for free meals, by removing stigma. (The community eligibility provision now serves nearly 20 million students.)
As for how universal programs can be paid for, the answer is, yes, imposing higher taxes. It might seem inefficient to give people a benefit if you’re going to essentially take it back from them in taxes, but what you actually end up with is a much more efficient program that is more easily administered and doesn’t leave anyone out.”
“There is a certain logic to Republicans’ commitment to pursuing Medicaid cuts: Social Security and Medicare are universal programs. Everyone pays in while they work, and then enjoys the benefits when they retire. Medicaid, on the other hand, is targeted to people who have low incomes. Republicans argue that this program, like food stamps and cash welfare, discourages people from seeking work, since they only qualify for benefits if their income is below a certain threshold.
“Assistance programs are supposed to be temporary, not permanent,” McCarthy said. “A hand up, not a handout. A bridge to independence, not a barrier.”
The problem is their diagnosis may be wrong. For starters, about two-thirds of the people covered by Medicaid — those who are children, elderly, or disabled — are usually exempted from work requirement proposals. Working-age adults who are expected to meet them can end up losing coverage even if they are attempting to satisfy it, if they have irregular work hours for example, or if they have trouble filing the necessary paperwork. One estimate of a Medicaid work requirement proposal in Michigan found that only about one-quarter of the people expected to lose their coverage were considered “out of work,” meaning they could work but weren’t. The rest were already working, retired, caring for a loved home at home, or unable to work for some other reason.
In Arkansas, where implementation of a work requirement was eventually blocked by a court order, nearly 17,000 people lost coverage after the requirement was put in place. Analyses later found that Medicaid beneficiaries had not started working more or earning more money as a result of the policy. Instead, lots of people got kicked off Medicaid, but it didn’t lead to an improvement in their economic status; they simply became uninsured.”
“Under current procedures, regulators typically assess pollution from new facilities or projects on a plant-by-plant basis rather than in conjunction with existing emissions from other sources. This method underestimates the health risks, community advocates say.
By instructing agencies to research and incorporate new data on those cumulative impacts and involving communities early in the process, Biden marries two of the “four historic crises” he identified on the campaign trail in 2020: climate change and racial inequality. Most people who face outsized health and climate vulnerabilities from concentrated pollution sources are people of color and low-income households.”
“a survey of more than 1,000 low-income Pennsylvanians found that taxes are often a major barrier to economic security—ranking ahead of more commonly discussed problems such as credit card debt and student loans. Among those surveyed, all of whom have incomes below 200 percent of the federal poverty level (about $53,000 annually for a family of four), the average respondent reported paying $4,575 per year in taxes.”
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“The paper asks officials to consider a counterfactual history: If Pennsylvania had enacted a rule in 2003 that capped future government spending increases at a combination of inflation and population growth (and had returned the surplus to taxpayers), the average low-income resident of the state would have an extra $20,000 in the bank today, simply due to the lower tax burden.”