What’s the purpose of the Medicaid program? Is it to provide health care coverage to people who cannot access it on their own, so they can lead healthier lives? Is it to fill health care gaps during epidemics and disasters, while ensuring hospitals and emergency rooms are not left with unpaid bills? Or is it Medicaid’s role to encourage people to find employment, so eventually they “drain” fewer resources from the government?
If you ask the analysts at Americans for Prosperity, a right-wing group founded by the billionaire Koch brothers, the answer is the latter. They argue that the “goal” of any safety net program should be “helping people improve their own lives” and “reduce their dependency on government.” Of the nearly 68 million Medicaid recipients nationwide, 25 million are adults who do not receive a monthly check for living with a disability, so Americans for Prosperity concludes there is fat to trim — and people who should find a job.
Conservative leaders nationwide have endorsed this reasoning as they push back against Medicaid’s expansion under the Affordable Care Act (ACA). Eleven states have applied for federal waivers allowing their Medicaid programs to require that adult enrollees work a certain number of hours each month — or at least have a “good reason” not to — and the Trump administration has signed off on four so far. President Trump says work requirements would “lift our citizens from welfare to work.” However, it turns out most adults covered by Medicaid who can work are already working.
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New analysis by the nonpartisan Kaiser Family Foundation finds that only 6 percent of those covered by Medicaid in the 11 states moving to implement work requirements are not already working and are unlikely to qualify for an exemption. A majority (62 percent) of non-elderly Medicaid recipients who do not claim Social Security for a disability have jobs, and about two-thirds of these enrollees work full-time. The rest report that they are in school (6 percent), living with an illness or disability (15 percent), or busy caring for children or an aging family member at home (11 percent), which generally allows them to apply for an exemption.
Work requirement waivers frequently target adults in good health and exempt some students and low-income parents, leaving a small number of people to be potentially “incentivized” toward employment. Of the 6 percent that would be targeted, 2 percent say they are retired from work, often due to bad health, and another 2 percent say they are unable to find work, according to the Kaiser Family Foundation.
Conservatives claim that Medicaid is swamped with people who are able to work but are unemployed and “living off the government dole.” In reality, Medicaid enrollees largely work in industries like retail, hospitality and fast food, where wages are low and hours often vary. As Kaiser reports, able-bodied adults covered by Medicaid tend to work service jobs with few benefits such as sick time and health insurance — which explains why they need Medicaid. Most are paid hourly, and over one-third of these workers are paid less than $10 an hour, far below what is considered a living wage in most of the US. For many, Medicaid fills a gap left by their employer, just like other social safety net programs.
While only a sliver of Medicaid participants are targeted, work requirements create more paperwork for a much larger number of participants. Under waivers issued by the Trump administration, working-age Medicaid enrollees in states such as Arkansas and Kentucky will be required to regularly prove that they are working a certain number of hours or qualify for an exemption. As Truthout has reported, advocates say people with disabilities and other vulnerable individuals are bound to fall through the bureaucratic cracks.
For example, Arkansas’s program requires an online account, but 31 percent of the state’s unemployed enrollees do not have internet access in their homes, according to the Urban Institute. Nationally, Kaiser found that nearly a third of all Medicaid recipients never use a computer or the internet, a sign that policy makers are out of touch with what poverty looks like in the US.
In states that did not expand Medicaid under the ACA, such as Oklahoma, Mississippi and Kansas, analysts say unemployed parents could find themselves in a “catch-22” under proposed work requirements. Even if they do manage to find a job to comply with the requirements, working part-time at minimum wage could lift their incomes beyond the state’s low eligibility limits for families, so they would lose coverage anyway. The Center on Budget and Policy Priorities breaks it down for families in Mississippi, where nearly one in three children live in poverty:
For example, to qualify for Medicaid in Mississippi, parents must have income below 27 percent of the poverty line, which is $370 a month for a single parent with one child. Under the state’s proposed Medicaid waiver, parents would have to work or engage in work-related activities for 20 hours a week to keep their coverage. Yet if parents were able to work 20 hours a week at the minimum wage, they would earn about $580 a month, too much to qualify for Medicaid in Mississippi. So, these parents could end up uninsured, because few low-wage jobs (especially part-time jobs) offer coverage, and their income would still be below the poverty line, which is the minimum income needed to qualify for subsidized coverage in the ACA’s individual insurance marketplace.
This explains why groups like Americans for Prosperity measure the success of work requirements by the number of people who drop out of social safety net programs, but offer few hard numbers on how many have “lifted themselves out of poverty” as a result. Research shows that work requirements are effective at trimming “welfare rolls” — a major policy objective for Republicans who just passed tax cuts for the rich. In the past, work requirements for welfare (along with various economic factors) may have contributed to relatively modest employment gains, but several studies have shown little evidence that they help most families boost their incomes enough to live without public aid, because the new jobs were often low-paid, part-time or temporary.
As the Congressional Research Service pointed out it in a 2014 report examining work requirements, “while work is usually necessary to escape poverty, it is not always sufficient to do so.” Having consistent health care coverage, on the other hand, can contribute to financial stability and make it easier to find and keep a job. That’s why the more liberal analysts at Kaiser and other policy tanks worry that work requirements would squeeze people who are not intended targets out of Medicaid, perhaps because they missed a deadline or were not scheduled for enough shifts at work.
Fewer people with insurance coverage means less federal spending on health care, unhealthier people and more unpaid medical bills at emergency rooms and clinics that are required to treat everyone, all of which drain resources from hospital and state budgets. By attempting to push a small number of unemployed participants into the workforce, work requirements could create headaches for everyone.