The legislative package passed by the US House of Representatives on April 26, 2023, would narrowly reduce federal spending over the next decade while raising the debt ceiling. One key measure in the Republican-backed bill would limit access to Medicaid for millions of Americans.
About 1 in 4 Americans have health coverage through the program, which serves mostly low-income and disabled people and is funded jointly by the federal government and states. If the Republican-backed law prevails, the federal government would require Medicaid adults who are 19 to 55 years old and do not have children or other dependents to spend 80 hours a month in paid work, job training or community service work.
The Conversation asked Simon F. Hader, a public health scientist, to explain what the proposed work requirements would do and why Republican efforts to enact them matter to the millions of Americans who rely on Medicaid.
What will change if this policy goes into effect?
Unlike some other government programs that help low-income Americans, including the Supplemental Nutrition Assistance Program, or SNAP, and Temporary Assistance for Needy Families, Medicaid currently has no work requirements.
The package the House recently passed would require all states to implement the policy. Approximately 15 million Americans with Medicaid will have to qualify.
This change would dramatically increase bureaucratic problems for Medicaid beneficiaries who are disproportionately low-income, disabled and non-white. KFF, a nonprofit health research organization, estimates that 1.7 million people will lose federal coverage. However, states have the option of continuing to pay for these individuals with state funds only.
Those who will be subject to the new rules will not be the only ones at risk. It is well known that many of the exempted population, including the elderly and the disabled, find it difficult to fill out documents or do not understand complex bureaucratic rules. Many experts predict that coverage losses could be even higher among these demographics because states will deem them non-compliant with work requirements.
Are there precedents for this policy?
This isn’t the first time Republicans have tried to make Medicaid access tied to work requirements for at least some beneficiaries. The Trump administration is working with various Republican-led states to use what are known as 1,115 demonstration exemptions for this purpose. These waivers allow states to make temporary changes to their Medicaid programs that deviate from certain statutory requirements. However, these efforts were quickly blocked in court. Most weren’t even piloted before the Biden administration canceled them.
One exception is Arkansas.
Arkansas began imposing work requirements on Medicaid recipients ages 30 to 49 beginning in June 2018. As a result, about 1 in 4 Arkansas residents subject to the policy ended up losing their coverage by the end of of the same year before the courts ruled it illegal.
The experience in Arkansas, which was particularly difficult for beneficiaries, confirmed many of the concerns of those who oppose work requirements. It’s important to note that the reason many lost coverage was not because they failed to complete the required hours of paid work, job training, or community service, but because they struggled to overcome bureaucratic challenges.
Efforts are also underway in Georgia to impose work requirements on Medicaid beneficiaries despite legal hurdles and objections from the Biden administration. With President Joe Biden in office, it will remain difficult to experiment with this policy unless Congress approves a measure like the one in the House package.
What would be different this time?
States had to actively seek these exemptions, which Republicans embraced when former President Donald Trump was in the White House. That meant Medicaid beneficiaries in Democratic-led states like California were unlikely to ever face them.
Proposed changes in the House legislation would force all states to implement work requirements for adults ages 18 to 55 without dependents. Failure to comply would put states at risk of losing federal funding, so even Democratic-led states would have to adopt these rules. The proposed changes would also circumvent many of the legal concerns that previously prevented the widespread implementation of Medicaid work requirements.
Importantly, this policy change will coincide with ongoing upheaval for Medicaid beneficiaries. That’s because millions of Medicaid beneficiaries are already losing coverage due to the May 11 expiration of the COVID-19 public health emergency declaration and the April 1 state restart of Medicaid beneficiary eligibility determinations. While the government’s continuous enrollment policy was in effect, states could not kick anyone off Medicaid as a result.
The number of people covered by the program jumped to 93 million by January 2023.
Is this policy consistent with the purpose of Medicaid?
Medicaid’s goal has always been to give eligible low-income people access to comprehensive health coverage for as long as they need it. That is, Medicaid is exclusively a health insurance program.
Some other safety net programs are supposed to accomplish multiple goals. For example, the official mission of Temporary Assistance for Needy Families is to “end needy parents’ dependence on government assistance by promoting job, job, and marriage preparation,” not simply to help those needy parents make ends meet.
At the same time, there is evidence that Medicaid leads to greater labor force participation because it provides affordable health coverage as well as access to needed medical care. If you have an illness, it can be much easier to stay in work if you are getting the treatment your condition requires. Indeed, most healthy adults on Medicaid are employed.
Ironically, pushing people off Medicaid, either because they don’t meet work requirements or because they find it difficult to navigate the red tape, is likely to reduce the number of people who work.
Why is this important?
Medicaid work requirements seem unlikely to become law in 2023 or 2024, as Democrats have staunchly opposed their implementation and the party holds a majority in the Senate. However, given the potentially dramatic consequences of defaulting on the federal debt, some Democrats may be willing to compromise.
For now, I think it’s much more likely that Republicans in Congress are setting the stage for future efforts to make more public assistance programs work-related, especially the next time a Republican becomes president of the United States.
If measures like the one passed by the House of Representatives as part of the Republican debt relief package become law, even states with established Democratic leadership will have little opportunity to fight back.
This article was republished from The Conversation, an independent, not-for-profit news site dedicated to the sharing of ideas by academic experts. The Conversation offers a variety of fascinating free newsletters.
Written by: Simon F. Haeder, Texas A&M University.
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Simon F. Hader receives funding from the Robert Wood Johnson Foundation and the Commonwealth of Pennsylvania.