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But Medicaid work requirements are a solution in search of a problem. Worse than that, they will create significant new problems, particularly among the vulnerable population the policy is supposed to help.
The perception that Medicaid is saturated with lazy shirkers is false. About 60 percent of nonelderly adults on Medicaid are already working, according to the Kaiser Family Foundation. Most of those not working either have a disability or serious medical condition or caregiving responsibilities, or they are enrolled in school — all of which happen to be among the specific exemptions laid out in the GOP bill.
If most Medicaid recipients are working anyway, or are exempt from the requirements, you might ask what’s the harm in asking them to provide evidence of their compliance? Perhaps in the process, you might also nudge some of those not working into gainful employment.
In theory, this sounds reasonable. In practice, implementation can be a Kafkaesque nightmare. We know this because it was tried in Arkansas in 2018, with backing from the Trump administration.
By the time a federal judge paused Arkansas’ experiment less than a year after it launched, 18,000 lower-income people had already been purged from the state Medicaid rolls — and not necessarily because they were failing to work 80 hours a month, as the state required (and as the new House GOP bill would mandate, too). Many were working but found it challenging to prove to the state that they met the “community engagement” requirements or allowable exemptions. That’s because the reporting process was confusing and onerous.
In fact, at least one person I interviewed at the time had been working, but was forced out of his work as a result of the reporting requirements.
Adrian McGonigal, a full-time employee at a poultry plant, had difficulty accessing the state website required to log his hours. He was abruptly disenrolled from Medicaid and was unable to afford the medications he needed to manage his severe COPD, a chronic lung disease that makes it difficult to breathe. McGonigal landed in the emergency room multiple times, missed too much work and ultimately lost his job.
In other words, for people such as McGonigal, access to health insurance and care should be seen as a work support, rather than a work disincentive.
A subsequent analysis of the Arkansas program, published in Health Affairs, found that it did not increase employment levels. But it did have long-term, adverse consequences for those who lost coverage. Of those purged, 50 percent reported serious problems paying off medical debt, 56 percent delayed care due to cost, and 64 percent delayed taking medications because of cost.
How much can we generalize from Arkansas’ experience? Its program did seem to be particularly poorly executed, after all. The state’s Medicaid enrollees were required to use a glitchy web portal, which perplexingly shut down every night from 9 p.m. to 7 a.m. (for “scheduled maintenance,” I was told). The site also didn’t work well on smartphones. Many lower-income Arkansans, McGonigal included, don’t otherwise have reliable access to the internet.
Theoretically, maybe Congress could design a version of this policy that would be less likely to harm “deserving” Medicaid enrollees. This would require a much bigger, more robust and more expensive bureaucracy, so that the state correctly identifies and penalizes only the tiny minority of Medicaid recipients not already working or with valid exemptions from work.
The cost of such a system might not outweigh whatever savings are achieved by purging those few “undeserving” loafers.
Helping more people find work, and move up the income ladder, is a worthy goal. But there’s little evidence that this particular policy would achieve that. It didn’t in Arkansas, and the Congressional Budget Office expects that the version included in the House bill wouldn’t, either. In a letter on Wednesday, the CBO concluded the measure “would have a negligible effect on employment status or hours worked by people who would be subject to the work requirements.”
On the other hand, the policy would result in roughly 1.5 million Americans nationwide losing federal funding for their Medicaid coverage, the CBO estimated. States would then have to decide whether to cut these enrollees loose or find and fund alternative means of coverage.
By all means, let’s help more Americans find jobs. Having bountiful job openings helps. Education, training and other government programs specifically designed to encourage work are all important, too.
So is keeping the populace healthy enough to work.
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