The Trump administration has finally made good on a long-standing threat to undermine Medicaid. The Department of Health and Human Services announced Thursday that it will look kindly on proposals from states to impose work requirements on Medicaid.
The agency doesn't call it a "work requirement," of course. It refers to "incentivizing community engagement among able-bodied, working-age Medicaid beneficiaries." It says "work or participation in other community engagement activities" could be a condition for Medicaid enrollment. The agency followed up on Friday by approving Kentucky's application to add a work requirement and other conditions to its Medicaid program.
Make no mistake: This is an unprecedented change of policy, and a dagger pointed directly at the heart of the Affordable Care Act's Medicaid expansion. That's clear from the coded language in the announcement by Medicaid and Medicare Administrator Seema Verma referring to "able-bodied" enrollees.
That's how conservatives and Republicans customarily describe the Medicaid expansion population, which for the first time encompassed childless, non-disabled adults in addition to the traditional Medicaid population of children, their parents, pregnant women, seniors and the disabled in low-income households. Conservatives have cloaked their attacks on Medicaid expansion by implying that its "able-bodied" recipients have been cutting into the resources for those needy populations. Indeed, the terminology has been used by Verma before, as in this Nov. 7 speech at a Medicaid conference.
Verma tried to put an uplifting spin on the new policy on work requirements: "We owe beneficiaries more than a Medicaid card," she tweeted; "We owe them the opportunity and resources to connect with job skills, training and employment so they can rise out of poverty."
A few points need to be made about this.
First, Medicaid is a healthcare program. It is not now, and never has been, a jobs program. Imposing work or job search requirements can only interfere with its main purpose, in part by discouraging its target beneficiaries from signing up.
This factor alone is likely to produce legal challenges to the Trump policy: Although the law allows HHS to waive certain Medicaid rules at the request of state officials, the law requires that those changes be "likely to assist in promoting the objectives" of Medicaid. Work requirements, which discourage rather than encourage enrollment, don't meet that test, which is why they were consistently rejected by the Obama administration.
Second, redefining work as "community engagement" doesn't fool anyone. Who do these people think they're kidding? They're trying a cynical subterfuge to conceal that they're adding a work requirement to Medicaid.
Third, work requirements are just a stalking horse for imposing other obstacles in the way of Americans seeking Medicaid. We know this from the record of Kentucky, where Republican Gov. Matt Bevin started with a work requirement, and moved on in his proposal for a waiver of Medicaid rules into a fully punitive plan that imposes premiums on the poorest residents of his state and threatens to throw enrollees off their coverage for as long as six months for missing a payment.
Bevin announced that Kentucky Helping to Engage and Achieve Long Term Health, or the Kentucky HEALTH program (the name of which sounds like it was crafted by the Dept. of Redundancy Dept.) would launch in July. He said that 95,000 out of the more than 440,000 Medicaid expansion recipients could lose their coverage as a result of the new requirements, speaking as if this were a good thing.
"It will be transformational," he said at a news conference. "Something we have not seen in America in a quarter century." Yes, that's true.
No one who understands that Medicaid's purpose is to provide people with healthcare would even think of proposing a system like that. The proposal is still before HHS, but it's expected to be approved.
The most important points about a work requirement for Medicaid are that it isn't necessary and it doesn't work. According to a Kaiser Family Foundation analysis of census data, nearly 80% of adults on Medicaid already live in working families, and about 60% work themselves —without having been subject to a work requirement.
Of those who don't work, almost all have a good reason. More than a third are ill or disabled, 9% are retired, 30% are taking care of their home or family members, 15% are going to school, and 6% haven't been able to find work. Conservatives like to assert that Medicaid somehow suppresses the desire to work, but that appears to be a fantasy. Studies have found no evidence for it. For example, a study published in the journal Health Affairs in 2016 found that "Medicaid expansion did not result in significant changes in employment, job switching, or full- versus part-time status."
What the evidence does show, however, is that work requirements attached to social programs are ineffective. The best research involves TANF, or Temporary Assistance for Needy Families program, which replaced traditional welfare and added a work mandate. Several studies have shown that TANF recipients who are able to work do so whether or not they're subject to the requirement, which suggests that it's not necessary. Those who find employment end up in low-wage jobs, typically earning about as much as the TANF and food stamp benefits their earnings replaced.
"Work had not lifted them out of poverty or increased their income relative to what they had received from TANF and food stamps," one study found, contrary to Verma's aspirational language. The work requirements failed to reflect that many of the program enrollees faced social, educational or physical barriers to employment, conditions that are likely to be replicated among unemployed Medicaid recipients.
Moreover, the work requirements added bureaucratic burdens that affected program administrators as well as enrollees, sometimes severe enough to discourage enrollment. Maybe that's the point.
Of course, nothing's wrong with state agencies encouraging needy people to seek out employment, job training, even volunteer work. But they don't need Medicaid as a goad to set up such programs. More to the point, the Medicaid work requirement fails to recognize that good health is often a prerequisite to employment; turning that relationship upside-down or inside-out, so that people can't get healthcare unless they're working or seeking work won't bring people either health or employment.
It should be obvious by now that all this talk about raising people out of poverty by jeopardizing their healthcare is cynical persiflage. What's really going on is an attempt to turn Medicaid into a "welfare" program, which will make it easier to chop. The first step in that process is the depiction of its beneficiaries as the "undeserving poor," a depiction with a history that goes back a hundred years, at least.
Verma's line about "able-bodied" Medicaid recipients is part of a long tradition, and a thoroughly discreditable one. As the person in charge of bringing health coverage to millions of Americans, she should be ashamed.