January 11, 2018; Washington Post

In a radical departure from previous administrations, the Centers for Medicare and Medicaid (CMS) issued new guidance for state Medicaid programs, allowing states to implement mandatory work requirements for “able-bodied adults” eligible for Medicaid. To date, 10 states have requested that the feds grant permission for them to enact these requirements, and three more are considering doing so. According to the Washington Post, Kentucky’s application is first in line and could be approved as soon as this Friday.

This federal action is the latest in a series of Republican attacks on the program, from trying to repeal the Affordable Care Act to failing to failing to fund the Children’s Health Program to the refusal of many Republican governors to expand Medicaid.

Though CMS attempts to clear the way for mandatory work requirements by claiming that “working promotes good health,” the evidence overwhelmingly suggests that work requirements that force people off of public benefits “are more likely to harm their health and well-being” than to positively contribute to their climbing out of poverty. In fact, data from Michigan and Ohio indicate that the expansion of Medicaid helped residents improve their health so they could look for work or remain employed.

So why implement policies for which the evidence is not just thin but counter-indicative? It appears that there are two goals: to further humiliate and punish America’s “undeserving” poor and to cripple the Medicaid program in whatever way possible. Since Congressional Republicans have been unable to transform the program into block grants as they hoped to do with the repeal of the Affordable Care Act, they have sought other policy hooks to begin to dismantle the nation’s largest safety net program, which provides health coverage to one in five Americans.

To understand the policy goals here, it is important to look at who is covered by Medicaid. Of recipients, 60 percent are already working. They have Medicaid coverage because they earn poverty wages and don’t have access to employer-sponsored benefits. Of those who are not working:

  • 36 percent are ill or disabled;
  • 30 percent are taking care of homes and families (something it should be pointed out that is lauded on the Right for middle class women who sacrifice careers for family); and
  • 15 percent are in school already.

In other words, the new rules are not likely to drive more people to work (since those who can work already do so), but they are likely to force people off of Medicaid. Why is that?

As with work requirements imposed on welfare (Temporary Assistance for Needy Families) and SNAP (food stamps) beneficiaries, failure to complete onerous paperwork will disqualify recipients. Kentucky, for example, expects to see its Medicaid population decrease by nearly 100,000 people within five years, according to the state’s waiver application. People will be removed from Medicaid, for example, if they don’t report a change in income status or fail to report they are meeting the program’s requirements. (The Post reports that Kentucky’s application says that state plans to give people only 10 days to report any change in income they may experience). For people who may struggle with homelessness, drug addiction, mental health issues, poor English skills and the many other barriers to stability that come with being poor in America, such paperwork can be a bridge too far.

“Work requirements are completely counterproductive—they block access to health services that individuals need to get and keep a job,” states attorney Catherine McKee of the National Health Law Program (NHeLP) in a press release. “Repeated research shows that the vast majority of Medicaid enrollees work or can’t work for an understandable reason, such as a disabling condition.”

NHelp and other advocates suggest that the Trump administration is on shaky legal ground. Explaining, the Center for Budget and Policy Priorities notes that the goal of the Medicaid program is “to provide comprehensive health coverage to low-income people so they can get needed health services.” Waivers, such as the one issued for Kentucky’s program, must “promote Medicaid’s objectives.” Mandatory work requirements are intended to reduce access to coverage, and therefore, the Trump administration is likely to be defending this policy in court sometime soon.—Karen Kahn