President Donald Trump’s administration has provided states with a new weapon to exact revenge on lazy poor people who have the temerity to be on the losing end of the American economy and also sometimes need to go to the doctor.
For the first time in the five-decade history of the Medicaid program, the federal Centers for Medicare and Medicaid Services will permit states to impose work requirements on Medicaid beneficiaries. The agency issued new guidance to states on Thursday on how to win federal approval for this restriction on Medicaid eligibility.
The vast majority of able-bodied, adult Medicaid recipients are in families where at least one adult is working and qualify for the program because they have low-paying jobs that may not even offer health benefits, let alone insurance these workers can afford.
And never mind that there are a lot of good, sometimes unavoidable reasons why even a part-time job isn’t an option for people who, say, have chronic illnesses not severe enough to constitute a disability; or who are caring for an ill or elderly relative; or who are full-time parents; or who are enrolled in school.
And the next time the unemployment rate spikes and people find themselves out of work and uninsured, these work requirements are going to make it even harder for them to keep their lives together.
The policy the Trump administration is enacting are based not on data but on an ugly stereotype many Americans hold about people who rely on Medicaid and other programs to get by. Accordingly, 70 percent of Americans said they supported work requirements in Medicaid in a survey the Henry J. Kaiser Family Foundation conducted in June.
Imagine Ronald Reagan’s “welfare queen,” only this time she has diabetes and can’t be on her feet all day. The Trump administration’s solution to this woman’s problems is to make it harder for her to see a doctor and fill her prescriptions, so she gets sicker and is less likely to find steady work.
The Trump administration and Republicans supportive of work requirements for Medicaid enrollees portray this policy as benevolent, as a means of elevating people to the higher status of not being poor, as though being poor doesn’t create its own incentives to not be poor. Who would turn down a high-paying job with good health insurance if that were actually an option for them?
Here’s Seema Verma, administrator of the Centers for Medicaid and Medicaid Services, promoting the new policy:
That sounds lovely. But the more likely result will be people kicked off their health benefits and more people who don’t bother signing up because they don’t think they’ll be able to get them. In essence, some untold number of people will become less healthy and more financially vulnerable so that others who resent the “lazy” can feel even more superior to them.
It can scarcely be emphasized strongly enough that work requirements are a solution largely in search of a problem (unless the “problem” is that safety net programs exist at all, which is how a lot of people see it).
At best, the new Medicaid policy reveals an ethos that accepts denying help to many people if that’s the price of denying it to a single person who’s exploiting the system. There is no doubt such people exist, but policies like these put the burden of proof on everyone else to demonstrate they’re not idle fraudsters. They also assume the opposite of the truth, which is that most people who need help are shiftless.
According to data compiled by the Kaiser Family Foundation, about 25 million adults without disabilities have Medicaid coverage. Among those, 60 percent have jobs and 79 percent are in families with at least one worker. More than six in 10 of these families include at least one adult who works full-time.
These individuals are poor by any measure, including those who are employed.
In states that expanded Medicaid under the Affordable Care Act, adults earning up to 133 percent of the federal poverty level ― just a little over $16,000 a year for a single person ― qualify. Thirty-one states and the District of Columbia participate in the Medicaid expansion, and Maine is in the processing of implementing it.
In non-expansion states, adults who don’t have a disability and aren’t parents generally can’t enroll in Medicaid no matter how little they earn. Parents of poor children in some non-expansion states don’t qualify if they make more than half the poverty level, while others range from half all the way up to 133 percent.
Large portions of the Medicaid population would be exempt from the work requirements under the new federal policy, mainly children, pregnant women, the elderly and people with disabilities. In addition, the Centers for Medicare and Medicaid Services advised states to make accommodations for people deemed medically frail and those under treatment for opioid addiction or other substance-abuse problems.
In addition, the agency offers a fairly broad array of activities that would satisfy the work requirement. Enrollees can demonstrate, for example, that they have a job, are searching for work, are in a job training program, are committing time to volunteering, or are a full-time caregiver.
All of that, if implemented the way the administration says it wants it to be, would be more humane than not doing those things.
But those exceptions, exemptions and accommodations would have the effect of making the population of those who really aren’t working when they could be quite small, calling into question the point of doing any of this.
Plus, everyone not explicitly excluded from work requirements will have to prove that they’re in compliance. That means people who have jobs will have to prove it at regular intervals, and so will some people who are exempt for other reasons. That’s a lot of hassle, and that kind of hassle tends to suppress enrollment.
Other federal benefit programs have work requirements, including Supplemental Nutrition Assistance Program (also known as SNAP or food stamps) and Temporary Assistance for Needy Families (also known as TANF or welfare). Research shows that TANF’s work requirement hasn’t made recipients more likely to work or elevated them from poverty.
So the consequences of this new Medicaid policy are likely to be fewer people with health coverage and not very many people with new or better jobs, or with more money.
And it’s going to cost states a considerable amount to set up systems to monitor whether Medicaid beneficiaries are complying with new rules about employment or other activities. States that take up work requirements will be betting that enough people lose health coverage that taxpayers will save money on net.
Prior to Thursday’s announcement, Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, New Hampshire, North Carolina, Utah and Wisconsin had already requested federal approval for work requirements, according to the Centers for Medicare and Medicaid Services. South Carolina soon will join them, and others are likely to follow.
Several states asked President Barack Obama’s administration to okay work requirements as part of expanding Medicaid eligibility under the Affordable Care Act. But the Centers for Medicare and Medicaid Services rejected those proposals, saying they violated the laws that govern Medicaid.
And they might: Court fights are almost guaranteed once the federal government starts allowing states to implement work requirements.