For many, the New Year begins with a resolution to get healthy by working out. This year, the government resolves to force millions of Americans to commit to a new fitness goal: Start working, or you can’t have health care.
Such is the logic behind the so-called “work requirements” the Trump administration has presented as reform for Medicaid, the federal means-tested health-care system for the lowest-income Americans. Under the planned new Health and Human Services regulations announced last week, waivers will be granted to states willing to restructure their programs to force individuals who would otherwise be eligible for Medicaid to work—generally for about 20 hours a week—to qualify for coverage. So far 10 states have applied for the planned waivers: Arizona, Arkansas, Indiana, Kansas, Kentucky, New Hampshire, North Carolina, Maine, Utah, and Wisconsin. Most of the states recently expanded Medicaid eligibility standards under the Affordable Care Act, so those who newly gained coverage will be especially hard-hit. The plan purports to help the poor economically and health-wise, but its almost certain to make people poorer and sicker instead. Nationwide, the changes are expected to drastically reduce enrollment, arbitrarily denying millions of impoverished people access to life-saving medical services.
Anti-poverty and health-care advocates say the waivers, which enable state Medicaid programs to mandate employment for all so-called “able-bodied” adults, are not only cruel but irrational: The vast majority of working-age Medicaid recipients (excluding the elderly and people with disabilities) currently are already employed anyway. Those who aren’t are often facing severe employment barriers precisely because of poor health. According to the think tank CLASP, “over one-third of working-age Medicaid recipients not working are unemployed because of illness or disability.”
Making the poor work for health care may seem absurd, but it actually reflects a core idea of the conservative agenda to shrink the welfare state. Although historically, Medicaid was designed as a social protection for the most vulnerable, the new rules undermine the moral premise of the system by imposing a price on the right to health. Echoing the work mandates imposed under Clinton-era “welfare reform,” linking employment to means-tested federal benefits is a proven way to both reduce enrollment and further entrench poverty. Since those reforms of the late 1990s, hundreds of thousands of working families have been shoved off the welfare rolls, yet remain trapped in dire poverty.
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While the job requirements for welfare arguably had the aim of encouraging productive workforce participation, “disciplining” the poor by tying jobs to health care is even more punitive, since it probably will improve neither their health-care access nor their economic conditions—but instead just make them both poorer and sicker.
Those who would be forced to find work as part of the administration’s work requirements will likely be tracked into low-wage jobs that simultaneously lack employer-sponsored benefits and leave them ineligible for Medicaid, according to a Community Catalyst analysis: Essentially, they would make too much to qualify for Medicaid, but still not get any benefits from their boss. These workers would also fall into an ever-widening coverage gap: too “rich” for Medicaid, too poor for subsidized insurance the federal health-care exchanges. In the case of an “able-bodied” worker with a minimum-wage job, supporting a two-person household (for example, a single mom with a child), they would be excluded from Medicaid in all but five states. Even a two-income household with two kids, with both parents earning their state’s minimum wage, would only qualify for benefits in South Carolina, Tennessee, and Wisconsin. So in nearly every community nationwide, the poor would be triply punished by a combination of harsh Medicaid restrictions, exorbitant insurance costs, lack of decent job opportunities, and regressive minimum-wage policies.
According to Laurel Lucia, director of the Health Care Program at UC Berkeley Labor Center, “Most of those losing Medicaid would not be able to afford private coverage or to pay out-of-pocket for care.” Those without jobs are often “unable to work due to caregiving responsibilities, school, or disability.”
Even those who manage to work, she adds, will be stuck in low-wage, precarious jobs for which “employers are less likely to offer coverage.” These jobs would most likely be in sectors disproportionately employing women and people of color. Current Medicaid enrollees typically work in industries such as child care, restaurant and food services, retail sales, and home health care. Of the roughly half of the current working Medicaid population (about 5 million total), the majority are concentrated in the food services, construction, and school-related jobs.
The Republican budget doesn’t account for the long-term economic cost of the “savings” yielded by the work requirement. But social ramifications will be bleak, as the workers who will be made sicker and poorer are building our homes, feeding us, and educating our children.
Even under current regulations, Medicaid coverage remains utterly inadequate in services and coverage. Surveys of “able-bodied” working poor show that, due to barriers ranging from physical or mental injury to lack of time and knowledge, a huge proportion of those eligible for Medicaid have not even applied.
Under the conservative logic of this administration and Republicans more generally, the poor should be forced to have “skin in the game” when it comes to receiving health care, but the cruelty of the work-for-health-care rationale is laid bare by the fact that conservatives have zero interest in helping poor workers actually afford health care. As CLASP’s Suzanne Wikle explains, “If proponents of work requirements are serious about helping people find work, they would invest in skill training and workforce development programs rather than increasing red tape and making it harder for people to access health care.” But GOP lawmakers continue defunding the very education and social programs that the poor need to to become economically self-sufficient.
Adding insult to injury, some states propose to “soften” the Medicaid requirements by allowing community and volunteer services to qualify as work activities—generously “allowing” people to work for free, in other words, instead of for wages in exchange for health care. Given the social spending cutbacks expected elsewhere in the conservative budget proposal, more volunteer workers will certainly be in demand.
Medicaid used to operate on the premise that no one deserves to die of illness because of poverty. Now the safety-net program is being perverted into a system to make society’s most vulnerable both too sick to work and too poor to stay healthy.
