Medicaid Work Requirements Won’t Work and Are Likely Illegal

The Trump administration’s watershed decision to allow states to test a work requirement for adult Medicaid enrollees has rightfully sparked widespread criticism from doctors, advocates for the poor and minority and disability rights groups. Proponents are arguing that the new policy will give states more flexibility to experiment with different approaches for improving the health and well-being of Medicaid beneficiaries.

Yet states considering whether to enact the controversial strategy face major hurdles. They will have to figure out how to define the work requirement and alternative options, such as going to school or volunteering in some organizations; how to enforce the new rules; how to pay for new administrative costs; and how to handle the millions of enrollees likely to seek exemptions. Medicaid directors in these states are not even sure how many people will be affected by the requirement, calling into question whether it’s worth the added cost.

At the same time, what will these states do, if anything, to help Medicaid enrollees get jobs? After all, creating such a requirement seems to carry with it a responsibility to help low-income residents overcome employment barriers. Will states help pay for training, transportation or child care? How could a cash-strapped state like Iowa, which has steadily cut back human services programs for years, possibly take that on?

More than anything, the work requirement proposal appears to be yet another, but more subtle attempt to reduce the number of non-disabled adults added to Medicaid under the Affordable Care Act, which survived multiple attempts last year by Congress to repeal and replace it.

The most important points about a work requirement for Medicaid are that it isn’t necessary and it doesn’t work. According to a Kaiser Family Foundation analysis of census data, nearly 80 percent of adults on Medicaid already live in working families and about 60 percent work themselves.

Of those who don’t work, more than a third are ill or disabled, 9 percent are retired, 30 percent are taking care of their home or family members, 15 percent are going to school and 6 percent haven’t been able to find work. Studies have also found no evidence that being on Medicaid makes a person less likely to pursue work. A study published in the journal Health Affairs in 2016 found that “Medicaid expansion did not result in significant changes in employment, job switching, or full- versus part-time status.”

And though it should go without saying, it must be pointed out that Medicaid is a health care program and not a jobs program. Obviously, people in poor health have difficulty obtaining or keeping jobs. But this is important to note because the core objective of Medicaid laws is to help low-income people get health care. Not only does a work requirement not address that objective, it will likely lead to people losing health coverage – the complete opposite of Medicaid’s mission. That in itself appears to make the requirement illegal.

One last point: While at the moment Iowa isn’t among the states seeking to create a Medicaid work requirement, Kansas is. And as of last month, that state’s Medicaid director, Michael Randol, is now running Iowa’s Medicaid program.