The War on the War on Poverty

Maximus is barely known to taxpayers, but it operates in 41 states and has $2.5 billion in annual revenue.

ONE NIGHT LAST MARCH, Sue Fredericks ran into trouble. She had been watching snow accumulate for hours from her post at a 24-hour gas station. Busy stretches on her overnight shift were rare, on account of the size of the town in which she worked; with a few thousand residents an hour from Indianapolis, it is small and quaint, surrounded by corn and soy fields and featuring a shuttered Walmart. March marked Sue’s eighth month on the job, and she was earning $8 an hour. Around 4 a.m., Sue (who asked that I change her name) consolidated the trash into two bags, propped the door open, and, hands full, walked outside. Somewhere near the dumpster, her foot hit a patch of ice. Sue’s leg flew out from under her, and she landed on her right ankle. “I heard it snap and all,” she said later, but “I didn’t break it to where my bone was sticking out.”

Sue, who at 41 already had arthritis from a lifetime of mostly manual labor jobs, crawled inside, called a co-worker, and asked her to come in. The co-worker arrived at 5 a.m., and Sue, who had kept her sturdy boots on in hopes of holding her bones in place, drove to the house she shares with her friend Robin and Robin’s family on the outskirts of town. She took off her boots, propped herself up on her bed, and waited in the dark. When Robin got up an hour later, Sue asked for her opinion on the ankle; Robin (not her real name) took one look and insisted on going to the emergency room.

A couple of years earlier, Sue had gotten health insurance through the Healthy Indiana Plan, a Medicaid expansion under the Affordable Care Act. hip represented a political bargain between then-Gov. Mike Pence, who was hostile to public aid, and advocates who worried about the state’s 596,000 uninsured citizens. The program expanded access but required each participant to make a monthly payment—a feature proponents say gives people “skin in the game.” hip’s architect, a controversial consultant named Seema Verma, went on to advise a half-dozen states about similar programs. In 2016, then President-elect Donald Trump nominated Verma to head the Centers for Medicare & Medicaid Services, the vastly powerful agency that oversees both those programs and their insurance markets. One of her first actions was urging the nation’s governors to impose premiums for Medicaid, charge its low-income recipients extra for emergency room visits, and require recipients to get jobs or job training.

Sue’s experience with hip offers a preview of how such policies could play out. When hip first expanded, Sue, single and making about $150 a week after taxes, qualified. She got back on medications for anxiety, depression, arthritis, and emphysema.

Then, in 2017, the state asked Sue to show once again that she was eligible for hip. Sue took her paperwork to the local social services office, where a worker helped her fax it to headquarters. The state wanted verification of employment, but Sue didn’t have her boss’ signature because her boss was on vacation, so she sent the paperwork without it. When she got a letter saying her hip had been canceled because she did not prove her income, Sue called the program’s help line. Sue explained to the agent what had happened and asked how to fix it.

“They said I’d have to redo the whole process, and I got frustrated and I told them forget it,” Sue told me last summer in Robin’s living room. Sue, who is short and heavy, was in sweats and a loose fuchsia tank top with the words “Live, Laugh, Love” spelled out in purple lamé. “I get too frustrated, so I just leave it alone. I don’t want to say something I’m going to regret,” she said. When I asked what she meant, she grimaced and looked down: “Cuss ’em out.” Sue never managed to get back on hip, so when she broke her ankle in 2018 she had no coverage at all. By August, she was facing about $4,000 in medical bills.

Sue’s inability to stay insured is a knotty problem at the heart of the Trump administration’s ambitions to introduce work requirements for every public program aiding the poor in the United States, starting with Medicaid. Conservatives, drawing on the likely that someone’s going to be able to get a job,” says economist and Clinton-era Labor Secretary Robert Reich. “The whole notion of taking Medicaid away if you don’t have a job is upside-down.”