Work requirements for Medicaid
Inventing a problem
At the beginning of March, the Trump administration approved a waiver from Arkansas that would allow the state to introduce work requirements — also euphemistically called “community engagement” — into its Medicaid program. Arkansas will become the third state to have Medicaid work requirements approved, joining Indiana and Kentucky. Seven additional states (AZ, KS, ME, MS, NH, UT, and WI) have submitted applications to institute work requirements for access to Medicaid.
This change will make affordable health care even harder to reach for those who need it most. The new proposals will lead to a loss of coverage if enrollees aren’t able to show proof employment, and will even threaten the coverage of exempt individuals. Tracking everyone’s employment or exemption status will also increase the administrative complexity of the program.
The move is a dramatic shift in Medicaid policy. Previous presidential administrations have approved linking Medicaid to voluntary work search or job training programs, but this is the first time that CMS has approved linking proof of work to access to Medicaid. Research clearly links higher income with better health. Researchers and health professionals know this is because wealthy people can afford better health: better preventive care, better food, more time for exercise, etc. The Trump administration has justified work requirements by citing the link and instead suggesting that work itself makes people healthier. The assertion is wrong, and forgets the population that Medicaid serves.
While many think of the program as ‘health insurance for the poor,’ it’s much broader than that. In addition to low-income families and individuals, Medicaid covers people with disabilities and long-term services for the elderly. Many people who receive Medicaid benefits are physically unable to work. Of those who are able to work, the majority already do (primarily in food service, construction, or education, if you’re curious). Medicaid beneficiaries don’t need work requirements to encourage them to seek work.
Instead, work requirements will punish those who cannot prove their employment or cannot find a job. Indeed, many beneficiaries who don’t work are actively seeking work but face significant barriers to employment. In addition to income or health challenges, lack of transportation or education make finding work difficult. Many families also balance child care or caregiving responsibilities for elderly family members.
Perversely, in some states, requiring work will effectively bar people from access to Medicaid. In states that have not expanded Medicaid, like Kansas and Mississippi, income eligibility requirements are so low that even working part time at minimum wage would result in individuals making too much money to qualify for Medicaid and losing coverage. In these states, low-income people are stuck in a catch-22: you need work to receive Medicaid benefits, but working disqualifies you from Medicaid. Inversely, former felons that face legal roadblocks to work, will likely also be locked out of Medicaid programs.
In states where working won’t automatically disqualify individuals, health coverage is still threatened. There’s a reason I keep saying beneficiaries will be required to show proof of employment, instead of simply that they must work. Finding a job is just the first hurdle: people receiving Medicaid benefits will additionally be required to continually prove employment or risk losing coverage. Evidence suggests that this will lead to coverage losses even for those who meet the requirement. Research from TANF work requirements suggests that those with complex health needs or disabilities are more likely to lose their benefits because they are unable to complete proof of eligibility.
While those being forced to show proof of employment comprise a very small portion of Medicaid beneficiaries (approximately 3–13%), the new work requirements will impact all beneficiaries. Under the new rules, most Medicaid beneficiaries will be exempt from work requirements due to age or disability reasons, but still need to document their exempt status. This means that even those exempt from work requirements will lose coverage if they fail to prove their exempt status, threatening the care of anyone in the program, working or not.
States will also face the burden of additional administrative complexity. Tracking employment and exemption status for each member means the overall program will be harder and more expensive to run. As an added wrinkle, CMS requires that states must also establish programs to help Medicaid beneficiaries meet these work requirements, but that federal Medicaid dollars cannot be used to serve this purpose.
The majority of Americans rely on their employer for health insurance, a relationship built on the understanding that employees must be healthy to work. For those who fell through the cracks, we created Medicaid, a program to provide access to health care for America’s most vulnerable people. Instead, CMS Administrator Seema Verma and the Trump administration insist that you can work your way to health. In doing so, they turn away from the reason Medicaid was created and expanded over the past 50 years. Introducing work requirements to Medicaid will change the face of the program, and move health care further out of reach for marginalized people.
