There are plenty of rules that determine whether or not someone qualifies for Medicaid, the public health-insurance program available to low-income Americans, but having a job hasn’t been one of them. That’s about to change: The Trump administration has announced that it will grant state requests to add work requirements to their Medicaid programs, forcing recipients to look for or obtain employment in order to receive benefits.
Work requirements are a solution to a nonexistent problem. Nearly 80 percent of adults on Medicaid live in a family where someone is employed, and the majority work themselves. The Affordable Care Act’s expansion of Medicaid to more people didn’t make individuals any less likely to work.
Those without full-time jobs, meanwhile, have good reasons. One in five people who work part-time say they can’t find full-time work, while another 28 percent have school or family conflicts. Among those who don’t work at all, more than a third say it’s because they have a disability or illness that won’t let them. Another 30 percent are taking care of their families and homes, while 15 percent are in school and 9 percent are retired.
The supposed justification for forcing poor people to work in return for their health care is that, as Centers for Medicare and Medicaid Services administrator Seema Verma explained, it will “help people in achieving greater well-being and self-sufficiency.” In other words, it will push them into a job that they were previously too lazy to get.
But we’ve run this experiment before, and it drove hundreds of thousands into abject poverty.
In the 1990s, Congress overhauled the country’s cash-assistance welfare program, now known as Temporary Assistance for Needy Families, adding strict work requirements. Ever since, poor people can be thrown off the rolls if they fail to work or look for a job.
The idea then was similar to the one being peddled now: that this would prod people to enter the paid workforce, which would leave them better off. Instead, it has erected a cruel barrier. Those who stopped receiving assistance because of work requirements initially saw an increase in employment compared with those who weren’t subject to them. But five years later, they were employed at the same or even lower rates. In Maryland, for example, over a third had no job at all.
Having a job didn’t necessarily mean people’s prospects improved, either. Only about 22 to 40 percent of the people who were subject to work requirements had stable employment years later, and many of their incomes remained well below the poverty line.
This trend has continued. In 2011, Kansas began mandating that anyone who needs welfare either work or search for a job before receiving benefits, and started kicking entire families off the rolls for three months if anyone failed to meet the work requirements. A year out, less than half of those who were sanctioned for not meeting the new rules worked in any given quarter. Four years on, nearly all of these families were still living in poverty, with median incomes of just over $2,000 a year. A third had no earnings at all.
Overall, the share of people who don’t have a job and are unable to get cash assistance has grown. In 1996, the year welfare reform was signed into law, about one in eight poor single mothers fit into this category. By 2008, the share rose to one in five. These women subsist on a median family income of just $535 per year. Alongside this has been a sharp increase in extreme poverty, defined as families who survive on $2 or less per person a day, which rose 159 percent from 1996 to 2011, particularly among those impacted by welfare reform.
There’s scant evidence that work requirements have helped people find good, steady work. Instead, they threw people’s lives into chaos as they had to contend with low-wage jobs and a threadbare safety net to catch them if they couldn’t make ends meet.
Now we’ll get to see how work requirements function in Medicaid. If what’s past is prologue, millions of people are in danger of losing health insurance without gaining anything in return.