“‘I don’t care of poor people…’” Photo Credit: emilius da atlantide

August 8, 2017; Post-Gazette

The relationship between employment and access to health care is a hallmark feature of the United States’ health care system. While this was not the case with Medicaid, the government-sponsored health insurance program for those living in poverty, the Centers for Medicare and Medicaid Services (CMS) announced earlier this year that states could apply for Section 1115 demonstration waivers that include a work requirement component.

Section 1115 waivers allow states to pilot an expansion of Medicaid services to those who would not otherwise be eligible or provide services that are not otherwise offered by Medicaid. Thus far, a dozen states have applied for Medicaid waivers with varying levels of work requirements. Pennsylvania’s General Assembly is currently considering legislation that would allow the state to seek an 1115 waiver with not only employment and job search requirements, but also restrictions on benefits considered nonessential, such as hearing aids, patient education, and dental care, which can help manage chronic conditions as well as prevent others.

Work requirements would apply to Medicaid-eligible individuals who are not pregnant, do not have a disability, and are not elderly. While Pennsylvania Governor Tom Wolf does not necessarily support the idea of work requirements, the legislation may sneak through as part of a larger budget bill. Further, it is possible that Pennsylvania’s 1115 application will get approved by CMS, as many aspects of former governor Tom Corbett’s 1115 proposal were approved, although plans were scrapped once he lost the election in 2015. Corbett’s proposed application was quite stringent, with 20 hour-a-week work requirements, mandatory completion of 12 job training activities per month, and declining eligibility for noncompliance.

The very idea of Medicaid work requirements is wrong for several reasons. To begin with, work requirements are in opposition to the parameters set forth by Medicaid for 1115 waivers, which include criteria to “increase and strengthen overall coverage of low-income individuals” and to “improve health outcomes for Medicaid and other low-income populations.” Increasing eligibility criteria makes it more difficult for low-income individuals to receive coverage. Further, implementing a work requirement changes the goal of Medicaid from health insurance coverage to a welfare program that seeks to get people off government assistance.

Thirdly, good health is an unstated requirement for employment. Individuals cannot go to work when they are dealing with chronic health conditions or pain. If they lose their job due to missing too much work, and then eventually lose health coverage because they are not employed, this cycle places individuals who are already vulnerable at an even greater loss with no way out.

Lastly, work requirements fail to take into consideration that the majority of Medicaid recipients already work without being required to do so. Those who are not currently employed have a valid reason, such as an illness or disability, caregiving, student status, or a current search for work. Thus, a large financial burden would be undertaken by the states to administer a program with little return.

These are just three reasons that work requirements should not be a criteria of Medicaid eligibility, but there are many more. As more states apply for 1115 waivers including work requirements, legislatures and advocates need to consider what purpose Medicaid serves and why a basic right such as healthcare is tied to employment.—Sheela Nimishakavi