I’ve been thinking about healthcare recently. I’m going to say some things I haven’t heard anyone else say. That is often not a good sign. As usual, I am going to start at several apparently unrelated starting points and as usual, I am going to try to bring them within speaking distance of each other.

Psychiatry

I don’t know much more about Freudian therapy than you can easily get from books and movies. [1] The picture I am relying on here is the patient lying on the couch free-associating in the presence of a fully present therapist. The “free” of free associating means, in part, that the little boxes in which we keep the thoughts and feelings that contradict each other are all opened at the same time in free association. And they associate with each other, not in the dark safety of the mind but in the public space between the therapist and the patient. Both hear the patient say things neither has ever heard before. [2]

Now I want you to picture President Trump as the therapist and the conservative core of his support as the patient. The patient is being encouraged to say, out loud, feelings and beliefs that have been publicly frowned on for many decades now. But instead of thinking that exposing them will rob them of their insidious power over the patient, the idea here is that it will reformulate them as public policy and give them a great deal of power over everyone. In fact, it will give them the power of law.

Federalism

Since the Great Realignment began around 1970, the two major parties have become much more internally consistent that ever before. [3] Now we have, not two parties, each of which has a right-ish wing and a left-ish wing, but a left wing party and a right wing party.

That is easy to see in a red state and blue state map of the United States. And year after year, red states want to do red state things and blue states want to do blue state things. And every year, each color has to put up with federal regulations that requires them to be much more similar than they would really like to be. This tension between the national administration of national systems and the state preferences which express the political culture of their own states, is the heart of the federal bargain.

Healthcare

For example, some states think that “welfare services,” thinking particularly of medical services at the moment, need to be earned. This the the cri de coeur of the red states. “Working” is good. Receiving benefits apart from working is bad.

The red states have been slapped on the wrist for many years now by the Great Father in Washington, who says that their hearts can cry out all they want, but their Medicaid administrators may not withhold medical benefits by enacting a work requirement. Note carefully that this is a constraint on the behavior of healthcare administrators in red states. It has nothing to do with what I called earlier, the cri de coeur of those states.

So the first thing to notice is that those states want, year after year, to do this. They want it when the economy is booming and they want it when the economy is busting. Only the rationales change; the desire stays the same. During liberal administrations and conservative administrations, they want this. And because it is a federal requirement—you may not, however much you want to—make the availability of medical services contingent upon “work” or “looking for work.” [4]

And why do they want to do this? One answer is that it is the right thing to do. They hold a view of “working” that is essentially moral. Work is what establishes your full membership in society. [5] Work establishes the income that will allow you to purchase medical services or at least the insurance that will pay for the medical services. And if it doesn’t, you will still have done your part and therefore deserve the additional money the state contributes to your care. That’s what I mean when I call this stance “the moral view.”

And I mean to distinguish this “moral view” from the practical view. If you wanted to design a system that provided medical care to people who need medical care, this is not the way you would do it. What might be called “the red state prescription” will not only withhold medical care from many who need it, but it will also cost more than it would cost of offer treatment. Here’s an excerpt that explains why. You can see the whole article here.

Other states [in addition to Indiana] are considering similar proposals, but a recent redesign of West Virginia’s Medicaid program offers reason for caution. In 2007, West Virginia asked Medicaid-eligible individuals to sign a personal responsibility agreement to qualify for enhanced benefits. The agreement required beneficiaries to keep medical appointments, take medications, avoid unnecessary emergency department visits, and participate in health screenings.

Those who didn’t sign it — or couldn’t hold up their end of the bargain — had their benefits cut, and were enrolled in a basic plan that restricted prescription drug coverage, limited access to mental health and substance-abuse services, and excluded weight management or nutrition education programs. Both children and adults were subject to the agreement, which raised a basic fairness question: Children might be at the mercy of unreliable parents or guardians to follow the rules.

Less than 15 percent of those eligible signed the agreement, and more than 90 percent of children with Medicaid had benefits restricted. A central motivation of the program was to reduce emergency department use, but over all, people were more likely to visit the emergency room. There was no clear improvement in health or healthy behavior. The experiment was scrapped in 2010.

I’m pretty sure that this predictable ineffectiveness is not known in these red states, but I wonder if it would make any difference if it were. “Morality” as the source of public policy really doesn’t lead to “effectiveness” as an outcome. Here is the pitch, as I understand it.

If it’s the right thing to do, then it’s the right thing to do.

And besides, the people who will be harmed by it are not morally worthy people. We know that because they aren’t working. Further, they are not working because they choose not to work and in that choice, they forfeit their claim to society’s help.

And the federal requirements that we fund their chosen inactivity are now being rescinded by a conservative administration in Washington which “gets it.” This administration understands how resentful we are that we have had to fund all this laziness in our states and now we get a chance to do it our way. [6]

Nothing I have seen in federal policy has taken any account of the persistence of this red state desire. I have heard it criticized as cruel and also as ineffective. But eventually, some account is going to have to be given of why they continue to want to do this. Decade after decade, they have the same policy preferences. Does federalism mean that eventually, they get to do what they want to do? Or does federalism mean that the citizens in those states are protected against their governments by national programs that constrain them?

Conclusion

After many years of national administrations hostile to “work requirements,” the red states are finally being allowed to do what they have wanted to do for so long. It is this “permission,” that called to mind the image of Dr. Trump as the therapist and “the red states” as the patient. Dr. Obama kept telling them how they should feel—compassion, for instance, toward those not able to find work—and made them feel ashamed of how they did, in fact, feel. Dr. Trump is allowing those states to say out loud what they have felt for so long and is giving them permission to build systems tying work to medical service.

I think the red states will find, as Khular says in the excerpt above, that it doesn’t really work. But I’m not sure they will care.

[1] It isn’t that I haven’t studied it. It is that the climate at the University of Oregon when I was there was actively anti-Freudian. The Rogerians and the behaviorists and the cognitive therapists were all opposed to it, although for different reasons.
[2] I can see why that would be helpful. I get some of the same jolt less expensively by talking candidly to friends who routinely disagree with me and with each other.
[3] I think of Paul Ryan as the true exemplar of the Republican consensus, not Donald Trump.
[4] I am fully aware of the difference. When I moved to Oregon, I received unemployment compensation for awhile and the requirement was that I continue to “look for work.” So I did. I applied for and had interviews relating to jobs I wouldn’t have taken if they were offered to me. And side by side with those, I spent time getting to know the people who knew people who would eventually open the door for public policy work. So I do actually know the difference.
[5] “Real work,” that is, not being “a paper pusher.” The prejudice in favor of physical or at least difficult work is very common among the working class whites who form the hardest of the hard cores of Trump support. See Joan C. Williams, Reshaping the Work Family Debate: Why Men and Class Matter’ .
[6] Even if it hurts good people to punish the shiftless in this way, there is a theoretical perspective that sheds some light on it. It is called “altruistic punishment.” See the piece by James H. Fowler of UC Davis in the Proceedings of the National Academy of Sciences, 2005.