But with the state elections in Kentucky and Virginia this week, plus policy rollbacks recently announced in other states, things are starting to change.
Medicaid work requirements might sound reasonable enough. Ostensibly, they’re about helping poor people move up in the world, or at least making sure they’re not taking advantage of taxpayer largesse. If you buy the premise that poor people choose to be poor because poverty is just too darn comfortable, maybe taking away their access to insulin or inhalers is just the kick in the rear they need to go out and get a job.
But there are some problems with this punitive approach.
One is that, despite stereotypes about lazy moochers, most working-age, non-disabled Medicaid enrollees are already working, according to data from the Kaiser Family Foundation. Most of those not employed have a good reason, such as school enrollment, caregiving, illness or serious illness.
Others want to work but struggle to find steady hours because of lack of access to reliable child care or transportation. Some lack the skills, credentials or spotless criminal records necessary to maintain a steady, year-round job.
Given all this, correctly identifying and locating the small fraction of Medicaid recipients whom policymakers consider “undeserving” requires a massive expansion of the administrative state. Implementing the Medicaid work requirement program in Kentucky, for instance, would cost more than $250 million, according to a recent Government Accountability Office report.
Even with this expensive new bureaucracy, those whom the state considers “deserving” still get punished.
In Arkansas — the first state to actually implement these requirements — more than 18,000 people lost their health insurance over the course of a few months. Many of these Arkansans actually met the work requirements, or were legally exempted from them. Yet they were still purged from the insurance rolls, due to onerous and confusing reporting requirements.
Consider one such person whom I profiled last year, Adrian McGonigal. He was employed at a chicken plant and thought he had sufficiently documented his hours. He lost his Medicaid coverage anyway, leaving him unable to get the prescriptions he needed to manage his chronic obstructive pulmonary disease (COPD). He landed in the hospital multiple times and eventually lost his job.
That’s right: A policy intended to help poor people find jobs instead cost McGonigal his.
He’s not an outlier, either. A recent New England Journal of Medicine study found that the program reduced the insured rate without increasing employment. If anything, it may have decreased employment. Which wouldn’t be surprising. Multiple earlier studies had found that Medicaid expansions had helped people get or maintain work.
Besides their moral, fiscal and economic downsides, there’s another problem with these policies: They’re probably illegal.
Medicaid was created by Congress, which said the program’s core objective was to provide medical care to the needy. Taking medical care away from the needy pretty clearly contravenes this goal. As a result, a federal district court has now struck down Medicaid work requirements in three states (Kentucky, Arkansas, New Hampshire). A circuit court heard an appeal regarding the first two of those cases last month, and is expected to issue a ruling soon.
Undeterred, the Trump administration has continued to encourage states to add work requirements. But noticing the pain and expensive litigation these policies have already caused, other states have been shelving their own proposals.
In fact, just last month, two more states — Arizona and Indiana — announced that they were pausing programs that had already been approved by the Trump administration.
Then on Tuesday, Democratic electoral victories in Kentucky and Virginia raised expectations that these states will soon rescind their states’ policies as well. This would mimic a similar reversal from Maine earlier this year, when a Democrat replaced a far-right Republican as governor.
The progress isn’t universal. Georgia Gov. Brian Kemp (R) recently unveiled his own work requirements proposal — expected legal, administrative and human costs be damned.
But there are promising signs elsewhere. A handful of states — Montana, Louisiana, Pennsylvania — have pursued kinder alternatives to work requirements. This involves offering Medicaid enrollees help with job training or job search, rather than kicking them off the rolls.
Carrots, so they say, are good for your health. Or, in any event, probably better than sticks.