States could hypothetically impose work requirements in a (rather transparent) attempt to cover fewer people, thereby reducing their costs. Also, requiring states to determine who’s eligible for Medicaid based on work status would increase administrative expenses and tax administrative systems that are already overloaded, which could lead to more than a few people losing eligibility despite actually qualifying via administrative error and oversight.
Medicaid enrollees are even more vulnerable to any manipulation by states than TANF recipients are. That’s especially true in states that have expanded Medicaid eligibility to able-bodied low-income people under the Affordable Care Act. Enrollees there are much more likely to be poor men, and thus much more likely to be convicted felons than TANF beneficiaries. That means they are also likely to be barred from many likely employment options; work requirements will only hurt their prospects of ever making it out of poverty.
Individuals who qualify for Medicaid because of a disability, or who receive federal disability payments, are exempted from the AHCA work requirement. But that doesn’t cover every worker with disabilities: The Kaiser Family Foundation reports that many adults covered as “able bodied” under Medicaid nevertheless report significant impairments or disabilities and can’t work. They may be waiting for decisions from the federal government on their disability status or may have a disability that interferes with their line of work but doesn’t qualify for insurance—for example, computer users with severe, chronic migraines triggered by computer use.
Beyond the TANF comparisons, Katch points out that one component in particular makes Medicaid a potentially fraught target for work requirements: Medicaid is itself already a work-support program for low-income people. One of the basic underlying premises of providing public health insurance to is that keeping people healthy, able, and out of the hospital is a pretty good way of ensuring that they show up to work. The bottom line is that people need to be healthy to work, and people who aren’t healthy can’t.
“Because Medicaid works as a work support, [a work requirement] would be a bit of a vicious cycle,” Katch told me. She outlined a scenario where a hypothetical poor coal miner in West Virginia suffers from two problems rather common to those in his occupation and region—back problems and associated opioid use. He fails to secure work thanks to the back troubles, the addiction, or lack of treatment for either. If he were subject to a work requirement, said coal miner might be kicked off the very program—Medicaid—that pays for treatment that might allow him to re-enter the workforce. That could lead to a downward spiral of sickness and poverty. Medicaid, like the rest of the American safety net, is intended as a failsafe for those not able to find work, and taking it away for those who cannot work subverts its purpose.
Again, most people on Medicaid who can work do, and low-income people working demanding jobs often do so “until their bodies gave out on them,” Pavetti said. There isn’t much evidence that penalizing the Medicaid population for not working will improve the program, its outcomes, or job creation. Indeed, the only real outcome of a Medicaid work requirement is that fewer people will have access to Medicaid, which may be the point.