The contest for worst Cabinet member of the Trump administration is what we might call “competitive.”
How to choose among Education Secretary Betsy DeVos, who was last seen trying to defund the Special Olympics, and Homeland Security Secretary Kirstjen Nielsen, who has defended placing children in cages at the border, and Labor Secretary Alex Acosta, who stands accused of letting an alleged child molester off the hook when he was a federal prosecutor in Florida?
But let’s not overlook Alex Azar, the secretary of health and human services, who holds the healthcare of millions of Americans in his hands. Azar has stood silently by as the administration has systematically sabotaged the Affordable Care Act, which he is sworn to uphold.
Last week, when the Trump administration filed a legal notice stating that it supported a Texas judge’s ruling declaring the entire law invalid, Azar’s friends let it be known that he secretly opposed that action. But he didn’t say so publicly, which is all that would matter. If the law is ruled invalid, that would mean the loss of insurance for some 20 million Americans and a threat of loss for an additional 133 million who have preexisting medical conditions. It would raise prescription costs for millions of Medicare enrollees, and throw much of the American healthcare system into chaos. Make no mistake, people will die as a result. If Azar’s concerned about this, he isn’t saying so.
More disturbing, Azar has been fully complicit in the administration’s attack on Medicaid, which today covers 72.5 million adults and children. Trump’s most recent budget proposed a cut of nearly $800 billion over 10 years from the Medicaid and ACA safety net, a proposal that Azar raised no objection to.
Azar, furthermore, has been the prime mover in the administration’s effort to impose work requirements on Medicaid, a proposal that is certain to deprive millions of Americans of coverage—and has been declared illegal, besides. Since this is a scheme in which Azar is not merely a passive onlooker but an active agent, let’s take a closer look.
The imposition of work requirements on Medicaid became part of the Trumpian toolbox in early January 2018, when Seema Verma, director of the Centers for Medicare and Medicaid Services at HHS, published guidelines endorsing those preconditions for receiving Medicaid. She approved Kentucky’s application to waive Medicaid rules by imposing work requirements, which had been pending, the very next day. As it happens because Kentucky’s program was held up in federal court, Arkansas actually became the first state to impose the rules, launching its changes in March 2018.
In June, federal Judge James E. Boasberg of the District of Columbia overturned the government’s approval of the Kentucky program. Boasberg observed that waivers to Medicaid rules were permissible only if they could be shown to advance the purposes of the Medicaid law.
Azar, who was by then the HHS secretary, couldn’t show that work requirements did so, especially since even the state acknowledged that the work rules might result in 95,000 residents losing their Medicaid benefits. In fact, Boasberg ruled, HHS hadn’t even considered the prospect of benefit losses before approving Kentucky’s waiver.
Kentucky slightly reworked its application and in November, HHS approved it again. Consumer advocates renewed their challenge in court, and last week, observing wryly that “the bell now rings for round two,” Boasberg tossed the work requirements again.
Boasberg this time was especially acerbic about a new argument advanced by the state and Azar’s agency. Kentucky’s tea party governor, Matt Bevin, had threatened to cancel the state’s Medicaid expansion entirely if it was barred from imposing work rules. Accordingly, the government argued, even though the work rules might cause nearly 100,000 residents to lose Medicaid, that was still better than the 450,000 residents who would lose coverage if Bevin canceled the expansion.
Boasberg wasn’t having any of it. He wrote that the state was trying to get its way by holding “a gun to the head” of the federal government … by threatening to de-expand Medicaid.” Boasberg said he wasn’t inclined to allow states to “refashion the program Congress designed in any way they choose.”
In any event, the government hadn’t dealt with Boasberg’s other problems with the work requirements. HHS maintained that work rules would promote “health and well-being” by prompting people to join the workforce and “achieve self-sufficiency” and “increase financial independence.” But those aren’t the objectives of Medicaid, which was designed to give low-income Americans access to healthcare.
The same day he threw out Kentucky’s plan, Boasberg invalidated the Arkansas work requirement, on almost identical grounds. The difference was that Arkansas already had implemented its program, with disastrous results. Because Arkansas requires its Medicaid clients to report on their work hours every month, using an internet portal that doesn’t even operate around the clock and may not be accessible to many residents without home internet service, nearly 20,000 residents already have lost their coverage. Boasberg ordered Arkansas to re-enroll them in Medicaid.
Despite Boasberg’s skepticism that work requirements and other obstacles actually served Medicaid’s objective of bringing low-income residents access to healthcare, Azar hasn’t given in.
“We are fully committed to work requirements and community participation requirements in the Medicaid program,” Azar told an audience at the right-wing Heritage Foundation in July, a few weeks after Boasberg’s first Kentucky ruling. He said his agency would keep encouraging states to devise new restrictions. “We will continue to approve plans, we are continuing to work with states and we’ll drive forward.”
During a March 21 appearance before the House Committee on Energy and Commerce, he even acknowledged that he has no evidence that work requirements do any good. In fact, he admitted that his department doesn’t even know why 20,000 Arkansans got thrown out of Medicaid. Nor could he produce a single study validating the assertion that imposing work requirements on Medicaid recipients makes them healthier or helps them find jobs.
As Rep. Joseph P. Kennedy III (D-Mass.) pointed out, “You propose implementing mandatory work requirements for Medicaid beneficiaries not knowing what the impact will be, across every single state.” Given that some estimates are that this change would deprive more than 4 million Americans of access to healthcare, Kennedy asked, “What’s the logic in that?”
Azar replied, lamely, that “for able-bodied adults, if you are receiving free healthcare from the taxpayers, it’s not too much to ask that you engage in some form of community activity.”
That may or may not be true. But as Boasberg observed, there’s no denying that it’s not in the Medicaid law, which is exclusively aimed at reducing obstacles to healthcare access, not erecting new ones.
The hostility Trump and congressional Republicans harbor for Medicaid is a byword. That’s unsurprising because it’s a program specifically designed for low-income Americans, for whom they show no sympathy whatsoever. Their animosity is based on their image of the “undeserving poor” — the notion that people are poor because of some underlying moral flaw, thereby justifying placing punitive limits on the assistance they’re provided.
Republicans reserve particular contempt for the Medicaid expansion enacted as part of the Affordable Care Act, which extended Medicaid beyond disabled persons and low-income families with children to low-income childless individuals.
Conservative rhetoric terms these additionally eligible people the “able-bodied,” a code designed to smear them as layabouts and malingerers who could get off their butts if they didn’t want a handout. One doesn’t hear the term only from right-wing pundits. It’s been used by Verma, head of the Centers for Medicare and Medicaid Services — that is, the chief administrator of Medicaid — and it fell from the lips of Azar himself during his March 21 appearance before the House Committee.
Azar’s policy-making raises the question of who he represents as secretary of Health and Human Services. He’s not Donald Trump’s employee, charged with implementing any medieval healthcare scheme Trump might conjure up; he’s a public servant, charged with doing what he can to improve the nation's health.
He's not in office to decide what Medicaid enrollees owe the taxpayers for their healthcare — that’s Congress’ job, and Congress decided that work requirements weren’t part of the deal. And he’s certainly not in place to help reduce the availability of medical care to residents of Kentucky, Arkansas, or anywhere else, no matter how bloodthirsty their governors and legislators might be.
When Donald Trump decided to encourage the courts to declare the ACA unconstitutional, Azar had one legitimate option if he disagreed — to resign. When Trump decided to undermine Medicaid by interfering with Congress’ vision of a program providing healthcare to low-income Americans, Azar had one option — to resign.