Last month, the administration began testing these policies at the state level. On January 11th, the Centers for Medicaid and Medicare Services (CMS) announced that states can now compel low-income people who rely on Medicaid to meet “work and community engagement requirements” in order to keep their health insurance. Within a day of making this announcement, CMS approved Kentucky’s plan to implement such requirements. The plan strips Medicaid coverage from most adults who fail to comply, including those who do not complete paperwork on time or report “changes in circumstances” quickly enough.

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All told, Gov. Matt Bevin’s office estimates that around 350,000 Kentucky residents will be subject to the new requirements and 95,000 will likely lose their Medicaid benefits. But once those people are booted from the program, Kentucky is giving them a chance to get it back: through “a financial or health literacy course.”

Of course, this is not the first time that Americans have been required to meet economic standards or pass a literacy test to exercise their rights. Discriminatorily applied literacy tests, known for their impossible difficulty, were administered by election officials who were given immense discretion over who to test, what to ask, and how to assess the answers when (mostly black) citizens attempted to vote. Similarly, extractive poll taxes disenfranchised poor black populations (and sometimes poor whites) from the end of the 19th century until the advent of the 24th Amendment (1964) and the Voting Rights Act (1965).

These methods were incredibly effective at preventing black people from voting. They led to dramatic drops in black voter registration in the South, and in the states that were the most egregious offenders—like Louisiana—black voter registration decreased by as much as 96 percent over an eight-year span.

Of course, the electoral arm of white supremacy in the postbellum era stretched well beyond such tools (and all the way to violent repression). Nevertheless, taxes and tests stand out as especially contemptible because they officially codified a logic of exclusion aimed at those presumed unworthy of American citizenship.

On the surface, Kentucky’s new Medicaid rules don’t look exactly like poll taxes or literacy tests. But there’s an equivalent logic of exclusion that holds across both domains: Those who are unworthy—either because of their race or due to their inability to access decent jobs—are ousted. Their political and social rights (like the right to vote and the right to be healthy) are sacrificed on an altar built by those with power.

Since social rights like health care are connected to political rights like voting, undermining one deteriorates the other. When Medicaid recipients are made to jump through hoops to prove that they are worthy of health care, they quickly figure out where they stand in the American social hierarchy. And once that’s clear, they have a diminished desire to participate in politics.

I know this because I spent years studying Medicaid and wrote a book about the politics surrounding it. I had in-depth conversations with people who use Medicaid; I observed  Facebook groups filled with Medicaid beneficiaries who readily recounted their experiences; I examined thousands of responses to large national surveys; and I scoured administrative records that detailed the actions that people with Medicaid took when they had scuffles with the government. I got to know some of the people who will find themselves at the losing end of the new Medicaid regulations, and I discovered how Medicaid shapes their political choices.

Take Angie, for example. Michigan’s Medicaid program stripped her coverage for not completing paperwork that she never even received. After battling for several months with local bureaucrats, she finally got her benefits restored. But by then she knew who she was in the eyes of the government:

“It’s like you are uneducated and you just want to get these free services and somehow you are inferior to other people if you receive those benefits … Once they hear Medicaid its ‘oh, one of those people.’”

Alienated from the government, Angie stopped voting and trying to advocate for herself. “I don’t do politics,” she said. When we talked about why she wouldn’t appeal devastating benefit cuts, she explained that she was a “nobody” and that the “powers that be” would not bend very far for her.

Angie was hardly alone. Ahmad fought back tears when he told me about the bureaucratic hurdles he faced after losing a limb in Iraq. Again and again he had to re-certify his enrollment, refile paperwork and find new medication when the old ones were no longer covered by Medicaid. He was clear on what this implied about his social status. “They treat us like we are stupid animals; like we don’t know anything,” he says. “I feel like I’m nothing, because when you are in Medicaid, they do whatever. You have to be on their rules.”

Just as literacy tests were applied unfairly by the election officials who administered them, adding stipulations to Medicaid will create opportunities for racial inequity. Blacks and Latinos face more labor market discrimination, have a harder time finding quality child care, and—because of biases in the justice system— are more likely to have a criminal record. In the face of such barriers, work and health literacy requirements pose burdens that will fall disproportionately on people of color.

That brings us back to where we started. Both types of literacy testing are predicated on assumptions about who deserves access to fundamental social and political rights, like health care and voting. Both also reinforce racial and economic inequality, whether purposely or inadvertently. Most crucially, both lead to the erosion of democratic citizenship among Americans whose political power has long been systematically suppressed.

If Lucy lived in New York, where I was born and now live, she would have access to health care. But her home state of Georgia had the second-highest percentage of uninsured residents in the country and did not plan to utilize the Medicaid expansion subsidized through the Affordable Care Act. As the summer of 2012 came to an end, she had difficulty getting her children signed up for Georgia’s Medicaid program and could not afford to pay for the immunizations required to enroll them in school. Adding to this, Tiffany, her eleven-year-old daughter, had a severe case of asthma, so Lucy placed a moratorium on all outdoor play. When Tiffany protested, Lucy regretfully explained, “You can’t go outside and play now, I don’t have Medicaid… if something happens and you have an asthma attack, I don’t have the medicine to give you.”

Lucy’s narrative is not unique. I have interviewed many Medicaid beneficiaries who recounted similar struggles. The details differ but the theme is clear: for Americans who live in poverty, the public benefits available to them are contingent on where they live. Your state legislature determines whether your kids are left without braces, whether your third degree burns remain untreated, and whether your illnesses go undiagnosed.

This is not an accident. Rather, it is a direct product of our nation’s enduring commitment to federalism, a political system that divides power between the national government and subnational entities, giving states and localities significant discretion in shaping policy outcomes.

Consider the perspective of Speaker of the House Paul Ryan, whose silver-bullet solution to poverty is to “consolidate many of our federal poverty programs into flexible programs that go to our states to customize a welfare benefit for a person’s particular need.” Ryan’s ideas are widely shared. When conservatives recently gathered in South Carolina for a forum on poverty, their devotion to increasing the power of states was on high display. Common proposals involved converting Medicaid and SNAP into block grants, which give states broad flexibility to design and distribute public assistance programs—with little oversight. While conservatives reason that states could leverage this increased control to tailor anti-poverty policies to the needs of local populations, evidence suggests that such grants are harbingers of retrenchment: dramatically decreasing the resources directed to the most needy and removing any guarantee of aid.

In addition to promoting harmful budget cuts, block grants are simply unnecessary. States already have plenty of power over anti-poverty programs like TANF and Medicaid and, in some cases, an infamous proclivity for misusing it. States decide whether to offer certain medical services to the needy, like dental benefits and eye care. They set income caps for various forms of assistance. They choose how often beneficiaries need to re-enroll, how burdensome application processes will be, and much, much more.

What it means to be poor in Mississippi is very different in Maryland and starkly divergent from Maine. It is clear that, in the realm of poverty, states already dominate. And to what end? There is scant evidence that local control is an effective way of alleviating poverty. Instead, research demonstrates that it undermines racial and gender equality and exacerbates geographic disparities. In short, unbridled federalism takes us down an inegalatarian path.

But perhaps most troubling, such a road leads us away from a robust democracy.

For Lucy, the first word that came to mind when I asked her about politics was, “dirty.” After nearly an hour of discussing how sharply Medicaid differed across states, I asked her if she thought this was at all connected to the political system. She deftly declared:

“Instead of sitting up high and looking low, they sit high and look higher… I don’t even know who my politician is, I don’t know who half of who the higher-ups are because they don’t branch out, they don’t make themselves known. …To us, sitting down here looking at those up there, it’s like our voice, what is my little voice going to do?”

Political scientists have already shown that citizens’ experiences with the government have profound consequences for democracy. When states use their considerable authority to retract services or limit benefits, struggling Americans’ views of government are negatively affected, and they exhibit decreased willingness to engage in politics. In particular, when individuals who bear the brunt of harmful state policy decisions become aware of geographic inequities in assistance, they can begin to view the political system as arbitrary and unfair. For instance, after John, a chronically ill Medicaid beneficiary from Michigan, discovered that he could not move with his family to Arizona without risking the loss of life sustaining treatment, he began to see the government as an oppressive force in his life. Similarly, when Terrie’s grandmother visited from out-of-town and Medicaid refused to cover her prescriptions, Terrie wondered, “what kind of government” would punish you for crossing state lines? People like John, Terrie and Lucy do not experience social policy in a vacuum, but rather within a multi-tiered political system.

Devolving power to states serves many purposes and can sometimes be quite beneficial. But when it comes to anti-poverty policy, federalism has too often been used to harm those who are most vulnerable. Policymakers must take care to limit those harms and ensure that they do not imperil democratic citizenship.

State residence is a basic condition of birth and circumstance.  Why, then, should it determine access to potentially vital resources like food or medical care? We cannot fully grapple with economic and political inequality unless we ask this question and press for better answers. There is a sordid history that links race, class and federalism in the United States. Learning from our past means listening to people like Lucy and challenging both the retrenchment and the ballooning geographic inequities that accompany block grants. It also means interrogating any policy that empowers subnational governments while disempowering low-income Americans.

*Name has been changed to protect confidentiality