The Human Cost of Work Requirements

After a grad student lost her Medicaid coverage, she turned to cocaine and painkillers.

hand picking up a pill
Anson Chan

When Donald Trump took the oath of office on a gray January morning in 2017, he laid out his vision for the United States under his leadership. “We stand at the birth of a new millennium, ready to unlock the mysteries of space, to free the Earth from the miseries of disease,” he said. “A new national pride will stir our souls, lift our sights, and heal our divisions.” Nearly four years later, the divide in how we view the consequences of his first term remains large. But the nation is undeniably changed. From family separation, to nation-wide protests and economic volatility, to a pandemic that has killed hundreds of thousands of Americans, Trump will leave behind a legacy—whether he’s reelected or not. We are telling the stories of seven individuals living with the consequences of Trump’s first term. You can read the rest of the stories here.

What Megan feared most in the early fall of 2018 was that she might end up in the hospital and have to be intubated. It was a reasonable fear. Megan, who I am calling by a pseudonym so that she can discuss her medical history candidly, has asthma. When she was a child, her breathing problems were easily controlled, but in college, her condition worsened. She often had asthma attacks that took her to urgent care or the emergency room. Later, she would learn that the concentration of chicken farms in the northwest corner of Arkansas, where she lived, could be hard on people with chronic lung conditions. She didn’t know that at the time; all she knew was that she kept getting sick.

She’d been intubated twice before. The first time, in 2015, was for 14 days, part of a six-week stint in the hospital. The cost for her stay approached $500,000. The second time was in April 2018. She was 26 and had aged out of her mother’s insurance coverage. She knew she couldn’t pay.

Thankfully, she didn’t have to. She had just been approved for Medicaid, which paid for part of it. But by the fall of 2018, Megan had lost her coverage due to a Trump-administration decision to allow states to attach work requirements to the program. The move was part of ongoing efforts to cut the budgets of many safety-net programs, including food stamps and housing assistance, by making it harder for people to qualify.

Losing her coverage meant that Megan couldn’t get the medicine she needed to control her asthma. It also meant that she could be one hospital stint away from financial ruin. “I’d pretty much already resigned myself to the fact that I’m probably going to have to file for bankruptcy one day for medical bills,” she said.

Medicaid had traditionally covered some of the most vulnerable adults, those with disabilities or who were very poor. The Obama administration expanded Medicaid to cover more low-income people, including the working poor. Arkansas was one of the first and only red states to accept the expansion, under its then-Democratic governor. Once Trump took office, his administration promoted attaching work requirements to Medicaid and told states it would approve their plans to do so. Seema Verma, whom he had appointed to head the Centers for Medicare & Medicaid Services, said that the Obama administration’s expansion of Medicaid had stretched the safety net too far. “The thought that a program designed for our most vulnerable citizens should be used as a vehicle to serve working-age, able-bodied adults does not make sense,” Verma said in a 2017 speech to state Medicaid directors.

Conservatives argue that work requirements encourage people to find jobs and have been pushing to include them in safety-net programs since the 1996 welfare-reform law, which introduced the requirements, passed under Bill Clinton. But a review of the reform law’s effects 20 years after its passage, by LaDonna Pavetti of the Center on Budget and Policy Priorities, showed that work requirements moved people into jobs only in the short term. They didn’t reduce poverty in the long term. What they mostly succeeded in doing was cutting people off from aid.

Arkansas was the first state to enact Medicaid work requirements under Trump’s new rule. Recipients had to earn at least $680 a month—roughly 80 hours at the state’s minimum wage at the time—and report their income regularly to the state. They could do so only online at first. Many of the estimated 18,000 people who ultimately lost their insurance in Arkansas in 2018 were the most at-risk: seasonal workers who couldn’t maintain the state’s $680-per-month requirement year-round, or people who didn’t have regular internet access.

Because she was a full-time student, in an online master’s program studying criminology, Megan thought the changes didn’t apply to her. She was also working about 14 hours a week as a server at a restaurant. The staff at the clinic where she first applied for Medicaid told Megan that college students were exempt from the work requirements, but they weren’t sure whether that applied to students in grad school, she said. “There was a lot of confusion amongst beneficiaries about whether it was going to apply to them,” said Kevin De Liban, an attorney with Legal Aid of Arkansas, who represented Medicaid beneficiaries in a lawsuit against the federal government.

Megan didn’t realize she’d lost coverage until she went to a pharmacy and her insurance didn’t go through. She never found out exactly why. When programs like Medicaid require recipients to verify their income or report to the state frequently, it creates more opportunities for people to be kicked off because of mistakes or errors in the system, a phenomenon policymakers call “churn.” Megan tried to find out what had happened, but every call to the state agency took at least two hours of wait time, and she struggled to get through.

Without Medicaid, Megan knew she wouldn’t be able to afford the hospital stay she feared was inevitable. Breathing problems sent her to urgent care twice in one month. Her ADHD, which she once managed with therapy and prescriptions, spiraled. “It was terrifying,” she said. In the restaurant world in Little Rock, she was surrounded by cocaine and painkillers. She started turning to them for relief. “I felt like I was functioning,” she said. And then she wasn’t. One day, she was doing laundry when her boyfriend heard a loud crash. “The dogs went crazy,” she said. “I guess I’d had a seizure.” She woke up in an ambulance.

Eventually, Megan went to a detox center she’d heard about from friends. It was there, in November 2018, that she learned she was pregnant. She was then enrolled in a special version of Medicaid for pregnant women that covered more of her medical needs and exempted her from the work requirements. Her baby was born in 2019. She said she got the best care of her life. She was given buprenorphine to help wean her off the pain pills and received regular psychiatric treatment and medication. Her health problems were under control.

Ultimately, the work requirements didn’t last—a federal judge overturned them last February. But Megan is still dealing with the consequences of her time without coverage. She has medical debt she can’t pay down. The worries and the problems she developed when she didn’t have insurance still haunt her, especially her problems with addiction. “I’m not saying it was because I lost Medicaid, but you know, maybe,” she said. “At the end, I was like, I’m going to die. And I didn’t want to die.”