Trump is weaponizing the welfare state to attack healthcare | Moira Donegan

5 hours ago 7

In United States v Skrmetti, a supreme court decision issued this summer, the rightwing justices made it legal for states to ban gender-affirming care for trans minors, in a ruling whose reasoning strained logic, claiming that state laws banning the treatment did not discriminate on the basis of sex. The ruling upheld laws in 27 states, all of them passed since 2021, which banned the treatment outright; according to the Human Rights Campaign, about 40% of trans minors live in states where treatment for them is against the law. Now, the Trump administration seems to be looking to cut off access to care for the other 60% of those kids.

In a proposed rule leaked to NPR, the administration plans to ban gender-affirming care for minors from being covered by Medicaid or by the Children’s Health Insurance Program, or Chip. In a second, more sweeping proposed rule, the Trump administration looks to ban hospitals, clinics and providers from receiving any Medicaid or Medicare reimbursements at all if their practice provides transition-related pediatric care.

If enacted, the orders – which NPR reports are scheduled for a rollout in early November – would dramatically reduce the number of providers able to treat trans teens, even in states where the care remains legal. Unable to keep their practices financially viable without reimbursements for care provided to Medicare and Medicaid recipients, the majority of medical professionals currently treating trans kids with puberty blockers, hormones or affirming forms of psychotherapy would be forced to stop providing such treatment. The result would be a back-door ban on transition-related care for minors nationwide: even in states that have not passed laws banning the care, like the one upheld in Skrmetti, trans teens and their families – even those are able to pay for the care – would not be able to find a doctor willing to help them.

The move is remarkably similar to one that the Trump administration and their allies have pursued with respect to abortion access. After the supreme court’s 2022 Dobbs decision allowed states to ban abortion, Republicans placed a provision in last summer’s budget reconciliation bill that excluded Planned Parenthood, the nation’s largest abortion provider, from receiving Medicaid reimbursements; the ban was later allowed to proceed by an appeals court. Abortions themselves are already almost entirely banned from Medicaid reimbursement; the bill went further, as the Trump administration’s proposed order on gender-affirming care does, by saying that no practice that provides such treatment can receive Medicaid reimbursements for any care that they give.

The exclusion of Planned Parenthood from Medicaid means that clinics are shutting their doors even in Democratic-controlled states where the procedure remains legal, making it much, much more difficult for women to end their pregnancies and restricting access to the care nationwide.

Technically, neither of these moves bans the targeted care: under the proposed trans care rules, and under the current Planned Parenthood Medicaid ban, none of the disfavored medical care is technically illegal under federal law, and states retain the option of allowing it. But just because something is technically legal does not mean that it is actually accessible: both of these policies function to place the medical care that gives these groups dignity, safety and control over their own lives out of their reach.

The proposed exclusion of youth gender-affirming care providers from Medicaid and Medicare, and the continuing exclusion of abortion providers from Medicaid, point to one of the Trump administration’s more perverse strategies for punishing disfavored groups and accumulating power: the weaponization of the welfare state.

Medicare and Medicaid were implemented to provide dignity and compassion to the nation’s elderly and impoverished. However flawed and partial these programs are their actual implementation, they are based on the principle that the state can improve the lives of its citizens, that it can catch those who fall prey to age or poverty, and recognize their membership in the American community with care. Above all, such welfare programs are tools of equality: they give Americans a degree of the dignity and freedom that are prerequisites to democratic citizenship. They prevent the kind of inequality that makes a farce of pretenses to republican government.

Now, with the exclusion of certain kinds of care from these programs, the Trump regime has inverted Medicare and Medicaid into handmaids of inequality, wielded to degrade, humiliate, marginalize and punish certain Americans on the basis of their sex and gender.

It is a playbook that the Republican right is using more and more. Under John Roberts, the supreme court has long been a fan of using statutes and constitutional amendments that were meant to mitigate racial inequality – like the 1964 Civil Rights Act and the 14th amendment – for ends opposite to those of the lawmakers’. This is why it is on the basis of a scurrilous claim of racial discrimination against white and Asian students that the court could bar race-conscious admissions policies at colleges and universities that are meant to more fairly distribute educational opportunities among Black youth. And it is why this spring, in a 14th amendment race discrimination case brought by “non-African-American” (read: white) voters in Louisiana, the court will almost certainly gut what remains of the 1965 Voting Rights Act.

The Trump administration has followed the court’s lead, subverting civil rights laws meant to curb inequality in order to entrench it instead. Of particular note is the Trump administration’s weaponization of Title VI of the 1964 Civil Rights Act against colleges and universities where students have staged pro-Palestinian and anti-genocide protests. The Trump administration has sought to marginalize pro-Palestinian speech and punish schools that do not crack down on it with false allegations of antisemitism leveled at these universities under the civil rights law. Using these lawsuits and threats of withdrawals of federal funding, the Trump administration has been able to not only ensure crackdowns on disfavored minorities, but ensure much broader changes at many targeted institutions to hiring, curriculum and admissions policies.

The welfare state, and the civil rights legal regime, have long been targets of the right; now, they have become their perverse tools, paths that the far right takes into Americans’ personal lives and most essential institutions in order to enforce a narrow, prescriptive and exclusive set of cultural values, namely white supremacy, sexism and a virulent transphobia. Those of us on the left will have to grapple both with the future of the welfare state and with the role of civil rights laws in a post-Trump world: as potent as these tools have been for ensuring a degree of dignity for Americans, they have also proved potent avenues for oppressing them.