Just because President Trump and the Republican Congress were unable to pass health care legislation that would have unwound the coverage benefits of the Affordable Care Act doesn’t mean such attacks are behind us. To the contrary, Republicans are now making an end run around Congress to accomplish one of their harshest goals: kicking economically vulnerable people off Medicaid.
The administration’s new approach — one that no administration before it has taken — is to provide waivers to states that allow them to impose work requirements for Medicaid benefits. Thus far, the Centers for Medicare and Medicaid Services has received requests for such waivers from 10 states. C.M.S. released guidance on Thursday describing how states can institute these work requirements.
Even before Thursday, C.M.S. had unilaterally changed the standards a waiver must meet to accord with Medicaid’s core mission — specifically, that whatever they do, states must increase and strengthen health coverage for people of limited means. Now the administration will be considering waivers that are likely to deprive thousands of low-income people of health care.
Some of these people will lose coverage because they can’t find jobs to fulfill the work requirements. Others will lose it because they fail to complete paperwork proving they’re working or that they qualify for exemptions. For example, people with mental illness, addiction or chronic disease often struggle to meet bureaucratic demands; in programs that already demand that beneficiaries work, such individuals have often been punished for falling short on work requirements even though they’re supposed to qualify for exemptions.
Instead of requiring states to increase and strengthen coverage, C.M.S. will now allow them to use waivers to promote “upward mobility” or “responsible decision-making.” If those sound good to you, understand that they are known euphemisms for work requirements. The key point, as the Medicaid analyst Jessica Schubel points out, is that neither of those goals align with Medicaid’s mission of providing comprehensive health insurance to low-income people. They would instead, she said, “let states kick people off coverage if they don’t comply with new requirements that have nothing to do with health insurance.”
People losing coverage could suffer severe harm. A study of Medicaid expansion in Kentucky and Arkansas found that it led to significant gains in access to care, financial security and health, with increases in the share of low-income adults going for checkups, getting regular care for chronic conditions and reporting that they are in excellent health. It also found large decreases in the share of people struggling to pay medical bills and relying on hospital emergency rooms for care. Under the new waivers, these gains will be reversed.
It’s also essential to recognize that Medicaid work requirements won’t work. There’s no evidence that Medicaid discourages work, which comports with common sense: You can’t pay rent or buy groceries with health coverage. About 80 percent of able-bodied adult Medicaid recipients are part of working families (that is, either they or their spouses work), and about 60 percent work themselves. Among adults on Medicaid who don’t work and could be subject to the work requirement, more than a third have a chronic health problem or disability, about half take care of their family or go to school, and just under 10 percent can’t find work.
It’s far more likely that Medicaid work requirements will backfire, at least in terms of improving beneficiaries’ living standards. By providing coverage for workers in jobs that are unlikely to provide such benefits, and by helping to stabilize the finances of people with illnesses, Medicaid has been found to help people stay employed or find work.
Of course, not all of the Republicans’ efforts to shrink Medicaid are occurring through executive, as opposed to congressional, action. The new tax law’s repeal of the Affordable Care Act’s individual mandate could, according to the nonpartisan Congressional Budget Office, cut five million from the Medicaid rolls by 2027. That’s because, absent the mandate, fewer low-income people will find out that they’re eligible for Medicaid, especially in expansion states.
By letting states impose work requirements in Medicaid, the administration will hurt many of the very people Mr. Trump said that he wanted to help when he ran for president. And announcing this policy in the wake of the tax overhaul makes the administration’s priorities especially stark: Reductions in coverage will be phased in alongside hundreds of billions in tax cuts for wealthy households and corporations.
Since congressional Democrats cannot stop the administration from issuing waivers, this battle now moves to the states. State legislatures and advocates for low-income families must insist that their representatives and elected officials not go down the path of requesting waivers. Medicaid is working, as are most able-bodied adults who are eligible for it. The administration’s bid to cut the program under the guise of mobility-enhancing work requirements must be seen for what it is.