I’ve long been a fan of HBO’s “Last Week Tonight” and its host, John Oliver, since his days on “The Daily Show with Jon Stewart.” Recently, Oliver produced a segment on the Temporary Assistance for Needy Families (TANF) program. TANF is a federal program that is designed to help low-income families make ends meet. The segment covers some of the myriad of problems with the program, most of which stem from mismanagement of funds by state officials. 

As with many problems in daily American life, we can track the cause of these problems back to Ronald Reagan. Reagan’s vilification of all things relating to government — especially any form of welfare — changed the narrative around fighting poverty. Bill Clinton’s welfare reforms in the 1990s shifted to a block-grant funding scheme, in which instead of federal oversight and cost-sharing, states receive a lump-sum payment and are told to run the program themselves. 

With that new freedom, states began to misuse the funding — using millions intended for poverty relief to fund financial aid, marriage counseling and anti-abortion centers. This misuse has continued to the present day. Meanwhile, some states simply refuse to spend the money allocated for the program, resulting in $5.2 billion in unspent TANF funds. Meanwhile, states that use the funds correctly (often, unsurprisingly, blue states), have found that there is not enough funding because the block grants were not tied to inflation and are woefully undersized.

Those in need — single parents, the unemployed and millions who desperately need this assistance — often find it out of reach. States set their own income thresholds and other qualifications, causing millions of people under the federal poverty line to be ineligible for assistance. 

TANF is just one of many federal programs that is funded with federal dollars and run by individual states. The Affordable Care Act of 2010 expanded the Medicaid program — meant to provide low-income people with health insurance coverage — but 11 states refused to adopt the changes. In a country that is ranked first in healthcare cost per capita, the willful exclusion of millions of our country's poorest citizens from healthcare coverage is not just bad policy, it is downright monstrous.

The programs being state-run also creates different levels of coverage. There are some basic services required, but states are free to add (or not add) additional coverage. Some states' Medicaid programs cover vision, hearing and dental, while others do not. If you are someone who is financially challenged in Alabama and need a cavity filled, you better be ready to shell out. Even in Pennsylvania — which adopted Medicaid expansion in 2015 — most dental procedures are not covered for adults.

When I needed a root canal in 2021, I was told that the tooth was not deemed medically necessary and was advised to pull it instead. Otherwise, I’d have to pay for the procedure out of pocket, with a cost of over $2,000. If I lived across the border in New Jersey, the procedure would have been fully covered, without even a copay. For all its faults, New Jersey is doing something right. 

I have made no secret of my support for Bernie Sanders in 2016 and 2020. A large part of that support was driven by his advocacy for what he called “Medicare for All.” This country needs to join the rest of the Western world in instituting a national healthcare system, and Bernie’s campaigns helped many realize the necessity of such a program.

Medicare has its own issues — don’t get me wrong. Parts of the program have huge copays, deductibles and act like the private insurance we all love to hate. While the Medicaid program has its own faults, I think, if run federally, it would be a much better model to build off of. In the 21st century, no one in our nation should have to pull out their pocketbook in a doctor’s office, emergency room or pharmacy. 

We spend nearly twice as much per person as any other country on healthcare, yet reap worse health outcomes than most Western countries. An American’s life expectancy is five years lower than the average from comparable countries. Maternal mortality is nearly triple that of Canada, and six times that of the average among comparable countries — a disparity largely driven by systemic discrimination against Black patients. 

Things need to change. We cannot allow partisan state governments to make these life and death decisions. Their negligence and willingness to let their citizens suffer is evidence of that. In this policy realm at least, our system of federalism has failed us. With one of our two national parties seemingly working inexhaustibly to make our country’s most vulnerable citizens’ lives worse, we need to reevaluate how these sorts of programs are run. 

There is no better way to “promote the general welfare” of our country than to ensure the health and economic security of its citizens. If we cannot trust state governments to operate in good faith and to efficiently use federal taxpayer dollars as instructed and for the betterment of their citizens, then the federal government needs to step in. 

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