Hidden Casualties

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In the early pre-dawn hours of May 21, 2025, the House passed H.R.1, also referred to as the ‘One Big Beautiful Bill Act.’^[1] In the days before and after the vote, news agencies flagged the proposed cuts to Medicaid, the nation’s largest social safety net program, documenting how the bill could cause millions of Americans to lose access to health coverage. However, they also noted other far-reaching consequences, such as its potential detrimental impact on rural hospitals that rely on Medicaid dollars to stay afloat, and the economic devastation facing low-income Americans who cannot afford unsubsidized coverage.^[2] While these stories are critical in understanding Medicaid’s impacts, one angle remains unexplored: how will Medicaid cuts impact the staff responsible for assessing requests for help? How will they prepare for a new reality that could lead to increased workloads and, worse, loss of their livelihoods? Operating in the shadows these workers, overwhelmingly women, have been a critical, but largely unknown, component of the social safety net.

In the United States, most individuals seeking Medicaid must first apply with their local welfare office. Although every state runs its programs differently, each agency employs and relies on eligibility staff, who are trained to review mountains of paperwork to determine what benefits, if any, an applicant qualifies for. Women have dominated the field of social welfare since the earliest days of the Republic when assistance was limited to private charity. Women’s involvement became institutionalized during the Great Depression as they leveraged their experience and engaged in what scholars refer to as ‘maternalist’ politics, using their roles as mothers and nurturers to influence national policy and join the federal bureaucracy.^[3]

When millions of Americans struggled to find stable employment in the 1930s, Secretary of Labor Frances Perkins helped federal government officials understand it was time for larger interventions. Thus, in 1935 as part of his New Deal, President Franklin Roosevelt signed the Social Security Act, which implemented a national welfare system for the first time. Crafted by Secretary Perkins and focused on income maintenance, the Social Security Act established both unemployment insurance and retirement benefits for the aged and provisions for children. Known as Aid to Dependent Children (ADC), the program gave qualified mothers a way to request monetary benefits for the care of their child(ren). Thirty years later, President Lyndon Johnson enhanced the Social Security Act when he signed an amendment establishing Medicare and Medicaid.^[4] Like ADC, the administration of Medicaid was delegated to the states, which relied on local county welfare offices and their staff to distribute benefits to those most in need. These jobs were predominantly filled by women who evaluated whether applicants qualified for services, and then worked with them to develop plans aiming at self-sufficiency and moving off the government dole.

Why women? Like many professions, women entered social services for several reasons. Some women were likely inspired by their contemporaries, such as Hull House leader and social work pioneer Jane Addams (1860-1935). Working in welfare also came with several benefits not typically available to women in the private sector. Government employment guaranteed these women a pension, health benefits, time off to enjoy their families, and the opportunity to build a career. Furthermore, unlike many industries open to women at the time, public service offered a pathway to leadership positions, which had historically been out of reach. Beginning in the late 1960s, federal administrators lowered the bar for women interested in pursuing a career in social welfare when they separated two key functions of benefit distribution: case management and benefit computation.

These new guidelines created a distinct job class accessible to women: the Eligibility Technician. Technicians processed paperwork and calculated the level of benefits, freeing up social workers to connect clients with resources and job training to help them wean off government assistance, with the goal of establishing independence. Eligibility Technicians, unlike social workers, did not need a college degree.^[5] Since women were still woefully underrepresented on university campuses in the United States, the Eligibility Technician role allowed access to stable, government jobs that had minimal entry requirements. This stability proved temporary. The separation of case management and benefit calculation caused the job to accidentally become “deprofessionalized,” leading to a false perception that the work was simple, easily automated, and could presumably replace the work done by women.^[6] This misunderstanding led politicians to begin searching for ways to streamline eligibility computation to rein in the steep costs associated with welfare administration.

With neoliberalism’s gaze focused on increasing efficiencies in welfare delivery in the 1990s, Eligibility Technicians faced a new hurdle with threats to privatize welfare computation and distribution. Combined with intense pressure from federal legislators on county agencies to adopt new technology to increase productivity, county welfare departments throughout the United States began installing computer terminals to assist workers with eligibility computation.^[7] Developed by programmers without experience in social welfare, these data systems often failed to account for the totality and complexity of an individual’s circumstances. “It just felt like this person wrote this, and that person wrote that,” recalled Tara Smith, a former Eligibility Technician. “You kind of had to figure things out.”^[8] Thus, line staff had to both determine what benefits their client was eligible for and how to enter the information into a benefits terminal to match their computation. The reliance on technology continued as Congress passed the Affordable Care Act (ACA) in 2011, which included a mandate to create an online exchange where Americans could enter their information and seamlessly enroll in subsidized healthcare coverage. Touted as a convenient, automated approach to insurance, the reality was entirely different.

When the ACA went live in January 2014, websites across the country faltered and the women behind the benefit desk shouldered the burden of formulating a plan to connect thousands with health coverage, despite lacking the resources to do so. “It was kind of a learn-as-you-go kind of thing,” former Eligibility Technician and trainer Tammy Reeves remembers.^[9] Mixing complex welfare regulations with tax codes and insurance rules further complicated benefit computation and delayed requests for help, forcing Technicians to devise creative solutions. Studies conducted by the UC Berkeley Labor Center concluded that in the state of California, Eligibility Technicians in county welfare offices–80% of whom were women–made the launch of the ACA successful.^[10]

Although Eligibility Technicians have long mastered complex and often conflicting welfare rules, local agencies still treat the role as entry level, requiring no prior experience. This perception partially stems from who sits behind the benefits desk. “It was considered secretarial type work,” Reeves remembers, “It really was ‘its paperwork. It’s just like being a secretary, it’s a woman’s job.”^[11] In a field where women still represent more than two-thirds of the workforce, Eligibility Technicians suffer from the double burden where both the public and local leaders underestimate the complexity of the field and the “political ambivalence shown toward social safety net programs” that is apparent in D.C., especially by Congress.^[12]

Since the current president signed the “Big, Beautiful Bill” with its proposed cuts to Medicaid, millions of Americans stand to lose access to health coverage, and those who seek benefits will likely confront significant delays as critical staff are laid off. Medicaid’s funding has always been the product of a state-federal partnership, which means cuts to the federal allocation would require states to either make up for the deficit with their own budgets or impose increased requirements to reduce the number of individuals eligible. When the cuts trickle down to county welfare offices, administrators will almost certainly face budget shortfalls that will likely result in staffing cuts. Similar to the Great Recession of 2007-2008, budgets dictate a department’s capacity to hire. “We had no hiring,” Reeves remembers, “because you’re at the mercy of a budget.” Lack of staffing does not equate to a reduction in demand and those left often face unmanageable workloads. “Caseloads would shoot up,” Reeves explained, “You’re working the people to the bone.”^[13]

Faced with steep budget cuts, local boards of supervisors and welfare agency heads must make difficult decisions. Cutting Eligibility Technician positions is often viewed as a better alternative to eliminating other jobs such as child protective services. Welfare administrators strive to save as many positions as possible, and some may get lucky to be placed in other departments. Unfortunately, the most likely outcome is that welfare departments across the country will be forced to lay off staff, not only reducing their capacity to respond to requests for aid, but potentially leading to some former benefit workers requiring the same services they once determined eligibility for. Prolonged reductions in staffing allocations could also lead to the loss of a rewarding career for women lacking college degrees. Without these women doing the quiet, necessary work of welfare, people in need of the social safety net may find that there is no one left to answer their call for help.

Notes

1. Kevin Freking and Lisa Mascaro, “Trump’s ‘beautiful’ bill spans more than 1,000 pages. Here’s what’s inside it,” AP News, May 21, 2025, https://apnews.com/article/big-beautiful-bill-trump-tax-cuts-medicaid-00ce1ff8a7b7fea7a894d38398748c6b. H.R. 1, “One Big Beautiful Bill Act,” 119^th Congress (2025), https://www.congress.gov/bill/119th-congress/house-bill/1. ↑
2. Nick Mordowanec, “Nurses Were Covid Heroes. Now They’re Being Squeezed by Medicaid Cuts,” Newsweek, June 9, 2025,https://www.newsweek.com/nurses-hospital-staffing-cuts-jobs-medicaid-2082106; Audrey Kearney, Isabelle Valdes, Liz Hamel, Ashley Kirzinger, and Lunna Lopes, “KFF Health Tracking Poll: The Public’s Views of Funding Reductions to Medicaid,” KFF, June 6, 2025, https://www.kff.org/medicaid/poll-finding/kff-health-tracking-poll-the-publics-views-of-funding-reductions-to-medicaid/, accessed June 18, 2025; Geoff Bennett and Karina Cuevas, “Exploring the potential impact of Medicaid cuts in Trump’s big budget bill, PBS News Hour, May 28, 2025, https://www.pbs.org/newshour/show/exploring-the-potential-impact-of-medicaid-cuts-in-trumps-big-budget-bill; “Medicaid Work Requirements Will Harm Low-Paid Workers,” Center on Budget and Policy Priorities, June 6, 2025, https://www.cbpp.org/research/health/medicaid-work-requirements-will-harm-low-paid-workers. ↑
3. James Leiby, A History of Social Welfare and Social Work in the United States, 1815-1972 (New York: Columbia University Press, 1978); Robyn Muncy, Creating a Female Dominion in American Reform, 1890-1935 (New York: Oxford University Press, 1991). ↑
4. Randall B. Woods, Prisoners of Hope: Lyndon B. Johnson, The Great Society, and the Limits of Liberalism (New York: Basic Books, 2016), 151; Laura Katz Olson, The Politics of Medicaid (New York: Columbia University Press, 2010), 2, 10, 23. ↑
5. “Golden West College Prepares to Train Welfare Worker Assistants.” Los Angeles Times, November 27, 1966, https://sonoma.idm.oclc.org/login?qurl=https%3A%2F%2Fwww.proquest.com%2Fhistorical- newspapers%2Fgolden-west-college-prepares-train-welfare-worker%2Fdocview%2F155618560%2Fse- 2%3Faccountid%3D13949; Margaret Schubert, “The Eligibility Technician in Public Assistance,” Social Service Review 48, no. 1, (1974), 51, https://www.jstor.org/stable/30015056; Job titles for benefit workers varies across the country. I’ve decided to use Eligibility Technician for simplicity in this article. ↑
6. Norman L. Wyers, “Whatever Happened to the Income Maintenance Line Worker?” Social Work 25, no. 4 (1980): 260, http://www.jstor.org/stable/23712091. Wyers used the term “deprofessionalize” to highlight the contrast of work experiences between social workers who normally held a degree and the income maintenance worker who did not; Jan Hagen and Ling Wang, “Roles and Functions of Public Welfare Workers,” Administration in Social Work 17, no. 2, (1993), 82. ↑
7. The Personal Responsibility and Work Opportunity Reconciliation Act of 1996,” Pub. L. No 104-193, Title One, Sec. 104, https://www.finance.senate.gov/imo/media/doc/confrpt104-725.pdf; Pamela Winston, Andrew Burwick, Sheena McConnell, Richard Roper, “Privatization of Welfare Services: A Review of the Literature,” Mathematica Policy Research Inc., May 2002, 3-4, https://aspe.hhs.gov/sites/default/files/private/pdf/72686/report.pdf ↑
8. Tara Smith, interview by author, August 2023. ↑
9. Tammy Reeves, interview by author, August 2023. ↑
10. Marissa Raymond-Flesch, Laurel Lucia, Ken Jacobs, et. al., “Lessons from the Medi-Cal Expansion Frontlines,” UC Berkeley Labor Center, October 29, 2015, 8, https://laborcenter.berkeley.edu/medi-cal-frontlines/; U.S. Department of Labor Bureau of Labor Statistics, BLS Reports: Women in the Labor Force: A Databook, (Washington, D.C., 2014, re-issued December, 2016), https://www.bls.gov/opub/reports/womens-databook/archive/women-in-the-labor-force-a-databook-2014.pdf ↑
11. Tammy Reeves, interview by author, August 2023. ↑
12. Christopher J. Jewell, Agents of the Welfare State: How Caseworkers Respond to Need in the United States, Germany, and Sweden (New York: Palgrave Macmillan, 2007), 179. ↑
13. Tammy Reeves, interview by author, August 2023. ↑

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Featured image caption: Posed picture of a welfare worker interviewing a woman at a desk in the Child Welfare Center, Washington, D.C. (Courtesy Library of Congress)