Michigan governor Rick Snyder may soon sign legislation making his state the third to seek a waiver for Medicaid work requirements with a suspicious exemption for counties that happen to be heavily white. Photo: Bill Clark/CQ-Roll Call,Inc.

Frustrated in their congressional efforts to “reform” Medicaid by ending its status as a personal entitlement and rolling back the expanded coverage that 32 states have chosen under the Affordable Care Act, Republicans in many states are now seeking to pare back Medicaid eligibility through work requirements that they hope will discourage enrollment. They’ve largely been given a green light by the Trump administration via waivers. But a new wrinkle in the way these requirements are drawn up is driving concerns (and lawsuits) based on suspicion that the idea is to make urban minority folk work while exempting rural white beneficiaries.

Kentucky secured a waiver to introduce Medicaid work requirements back in January, and there the way the new rules are being phased in has already drawn negative attention, as Alice Ollstein explains:

The waiver in Kentucky, the first state to win federal approval for a Medicaid work requirement, will have the effect of exempting eight southeastern counties where the percentage of white residents is over 90 percent. The work requirements will be imposed first in Northern Kentucky, which includes Jefferson, the county with the highest concentration of black residents in the state.

In a pending waiver request from Ohio, and in a bill passed by the GOP-controlled legislature in Michigan, counties with high unemployment rates are exempted from the work requirements entirely. These tend to be heavily white rural areas. Meanwhile, low-income African-Americans tend to be concentrated in large counties where low unemployment in relatively wealthy suburbs keep the inner cities from qualifying for the exemption.

John Corlett, Ohio’s former Medicaid director and the president of Cleveland’s Center for Community Solutions, studied the 26 counties that qualify for an exemption from the proposed Medicaid work requirements and found they are, on average, 94 percent white. Meanwhile, his research found, “most of these non-exempted Ohio communities have either majority or significant African-American populations.”

The same is true in Michigan, where the discriminatory impact of the proposed work requirement has gotten significant national attention, and not in a good way. The Washington Post looked at Medicaid data from the state and found a pretty dramatic disparity:

African Americans make up about 23 percent of that [Medicaid] population, but they would make up only 1.2 percent of the people eligible for the unemployment exemption. White people make up 57 percent of the total potential affected population, but they make up 85 percent of the group eligible for the unemployment exemption, according to an analysis of the state’s data.

The bill is still awaiting action from Michigan’s Republican governor, Rick Snyder. If he signs it, Michigan will get in line for its own waiver from the Trump administration. Based on the Kentucky precedent, the odds are high they’ll get approval.

Writing in the New York Times, two law professors from the University of Michigan suggested that any such waiver could and would be challenged under civil-rights laws. But they go on to address the underlying issue that supporters of Medicaid work requirements keep dancing around:

There’s a deeper lesson here. If work requirements were a good idea, conservative Michigan legislators wouldn’t need to exempt their rural constituents. They’d just offer a tough-love message: If you want health insurance on the public dime, you should move to a place where you can find work.

That’s not the message, though. The message, instead, is that work requirements are good for people who live in hard-bitten cities and bad for those who live in hard-bitten counties.

It’s not terribly surprising that white rural conservative legislators would like to find a way to crack down on those people receiving Medicaid benefits while expressing empathy for the plight of their own folk. But it’s also racist, if we are still allowed to apply that term to conservatives who earn it without upsetting enemies of political correctness.