Wendy A. Bach

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University of Tennessee Legal Studies Research Paper


In a 2018 letter the Trump Administration announced that it was open to proposals to include work requirements and other changes in state Medicaid programs. These proposals came in the form of administrative waiver requests that would allow particular states the flexibility to change the rules of Medicaid eligibility in their state. They were seeking permission to condition the receipt of Medicaid on compliance with work requirements and to “align” the Medicaid program with programs like Temporary Assistance to Needy Families. The Obama administration had consistently rejected such requests on the grounds that work requirements did not further the aims of the Medicaid program, but the Trump administration felt no such qualms, likening Medicaid to Temporary Assistance to Needy Families (colloquially welfare) and arguing that, just like welfare recipients, Medicaid recipients needed to be incentivized to work in order to “build” their dignity. This contest, like many others in the field of social welfare policy, plays out on the terrain of federalism. It is, on the surface, a battle over control among levels of government and over the appropriate rules and structures for particular programs. This chapter argues that these controversies over legal structures, legal rules, and the location of governance, are better understood as arguments about both deservingness and control played out through controversies about administrative structure. In short, programs are called “welfare,” or are urged by some to be more like “welfare,” when what is really meant is that we wish to use the administrative mechanisms of federalism to control, stigmatize, punish, and deter recipients. In contrast, when we perceive recipients as entitled, these mechanisms fall away to be replaced by federally-controlled, far less visible and far more inviting, administrative structures. To make this process visible, this chapter describes the administrative tools of benefit programs as well as the corresponding cultural assumptions tied to each program and then contextualizes a debate like the one over Medicaid work rules using this context.

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