Medicaid work requirements – morally regressive or just bad policy?

By Judith Garber

For people who say they don’t like government bureaucracy, Republicans sure like adding more requirements to public programs. The newest fad for red states is creating work requirements for Medicaid recipients, to reverse the “dead-end entitlement trap” of low-cost health insurance, as Kentucky governor Matt Bevin put it in his announcement of the new state policy. Nine other states have submitted waiver requests to add a work requirement to Medicaid, in accordance with the Trump administration’s new guidance

A highly illogical policy

From a policy perspective, this doesn’t make sense. As health care economist Aaron Carroll points out in a recent JAMA forum piece, the proportion of people receiving Medicaid who are able-bodied and not already working is low, somewhere between 3% and 27%. The administrative costs of making sure that Medicaid recipients comply with the requirements are not insignificant, and they may even exceed the savings the state would get by having fewer people “mooching” off the system, Carroll writes.

Besides not actually saving money, requiring Medicaid recipients to be working has another obvious downside — for low-income people with health problems, getting treatment makes it possible for them to look for and find work. Medicaid recipients who not working but categorized as “able-bodied” still face health challenges; they are more likely to be older, be in worse health, and have a chronic mental health condition, compared to those who are working, according to a recent JAMA study.  

Who’s “deserving”?

Carroll concludes by wondering “why so many states are eager to rush to implement work requirements for Medicaid recipients,” given the lack of evidence that the benefits outweigh the costs. The reason is not because these governors think it’s good policy, it’s because they want to whittle down public programs as much as possible and because they believe that only some poor people are “deserving” of aid.

Kentucky officials’ stated goal of “empowering people to improve their health” rings hollow. As many others have pointed out, we’ve seen this policy change before when welfare was “reformed” in the 1990s to add strict work requirements to SNAP (nutrition assistance) and TANF (income assistance). These changes don’t bring people out of poverty, they only reduce the number of people receiving assistance – which is the real point. 

These policies also perpetuate the false narrative about Medicaid recipients being lazy freeloaders. The idea that there are tons of people on Medicaid taking something they didn’t earn harkens back to the 90s, when politicians used the stereotype of the “welfare queen” to paint welfare recipients as undeserving (specifically single mothers of color).

Passing the test

Even more tone-deaf is Kentucky’s proposed “health or financial literacy course,” which looks disturbingly similar to literacy tests that kept African Americans from voting in the Jim Crow era. Why have Medicaid recipients pass a test before receiving care? Because it further stigmatizes Medicaid recipients and puts up additional barriers to access. It’s also part of the idea that we can’t just give people health care without them doing something to earn it.

This all serves to promote a view of health care not as a necessity everyone should be able to have, but something you must earn by being “deserving” – being elderly, a child, disabled, or working. However, most of America doesn’t think that way about health care anymore. Sixty percent of Americans believe it is the government’s responsibility to make sure everyone has health care coverage. And 52% would support a single-payer system, according to a survey from this past fall.

We have to pursue policies based in the view of health care as a right, that unite Americans in our ability to care for one another, rather than separate us further into damaging and unnecessary tiers of worth.