House Republicans have proposed adding work requirements to Medicaid, the health insurance program serving tens of millions of low-income Americans. Their plan, unveiled Sunday, would, with a few exceptions, strip coverage from childless adults who cannot document at least 80 hours of monthly employment.
Many Americans are intrigued by the idea of conditioning benefits on work. A recent poll from KFF, a nonpartisan health research group, found that over 60 percent of American adults supported such requirements, probably influenced by persistent myths about widespread unemployment among public assistance recipients.
Yet despite its potential political popularity, imposing work requirements on Medicaid is a fundamentally misguided policy. In the debate over work requirements, it is easy to get sucked into abstract moral theorizing about what a society owes people who can work but refuse to do so. This sort of philosophizing is interesting, but it tends to elide the fact that it is employers, not workers, who make hiring, firing and scheduling decisions.
Last year, over 20 million workers were laid off or fired at some point from their jobs. Many of those workers ended up losing not just all of their income but also their employer-sponsored health care. Medicaid is supposed to provide a backstop for these workers, but if we tie eligibility to work, they will find themselves locked out of the health care system because of decisions their employers made, often for reasons beyond their control.
Even workers who are able to get and keep jobs do not decide how many hours they are scheduled for. Many low-wage employers assign shifts based on real-time estimates of consumer demand, resulting in unpredictable work hours for their employees. Through no fault of their own, these workers frequently see their schedules drop below 80 hours a month. The resulting income instability creates significant hardships for them. Eliminating their health insurance would only make things worse.
The inherent unfairness of penalizing people for things they cannot control might be tolerable if it manages to result in a large employment increase. But it doesn’t. Arkansas tried Medicaid work requirements seven years ago. The state used the requirements to remove 18,000 adults from the Medicaid rolls in just four months. Yet subsequent studies found that it had no positive employment effect. This is one of the reasons even many conservative policy thinkers who generally support work requirements balk at using them for Medicaid.
There is not an epidemic of non-working able-bodied adults living high on Medicaid, despite such claims from the Trump administration. Medicaid work requirements are a solution to a problem that doesn’t exist. According to the Census Bureau’s current population survey, around 46 percent of Medicaid beneficiaries are children or people age 65 or older, age groups that are not expected to work.
Of the working-age beneficiaries, about half are working, and an additional quarter have a work-limiting disability. An additional one-fifth will work at some point in the next year or come off Medicaid sometime in the ensuing 15 months. This means that only 6 percent of working-age enrollees are not engaged in work long term, which is just 3 percent of the entire Medicaid population.
The main moral intuition underlying the appeal of these kinds of work requirements appears to be the idea that it is wrong for certain individuals to get something for nothing and that, instead, everything must be earned. While it is true that we live in a capitalist society where individuals’ standard of living is largely determined by how much money they can scrape out of capital and labor markets, there are some services — such as police, fire, library and education services — that are provided to everyone regardless of employment status.
Health care services have much in common with police and fire services. We turn to them when something has gone wrong, often unpredictably and catastrophically. Our society could decide that police and fire departments will not respond to calls made by individuals who worked less than 80 hours in the prior month, but most would find this repugnant and contrary to the purpose of these services. Likewise, refusing medical care to people in their time of need based on how much they happened to work the month before is a cruel and pointless policy.
Library and education services also have parallels with health care. All three provide people with resources that enable them to pursue other goals, including employment. Just as it would be counterproductive to promote work by denying unemployed people access to free internet and books, taking away their medical care is equally self-defeating. An unemployed person with an untreated broken bone becomes less employable, not more. Similarly, an unemployed person with diabetes lacking access to insulin faces diminished, not enhanced, job prospects.
Even if one believes, despite all the points above, that making health care contingent on employment is justified, it’s crucial to recognize that work requirements don’t magically identify who is and isn’t working sufficiently. Instead, they create increased paperwork and reporting burdens for all Medicaid recipients. Requiring proof of monthly work hours will cause some people to lose coverage simply because they struggle to keep up with the paperwork, not just because they’re unemployed.
One recent example of this is the unwinding of the Covid-era Medicaid eligibility rules. To determine which Medicaid recipients would still be eligible after the Covid rules were reversed, states sent out notices directing beneficiaries to submit paperwork to recertify their Medicaid status. Nearly 70 percent of the disenrollments that occurred during this unwinding were the result of procedural snafus — i.e., failure to file paperwork — not the result of individuals being assessed as ineligible.
For those fundamentally opposed to Medicaid and the welfare state more generally, the fact that these new requirements would create administrative barriers that disenroll eligible recipients may be seen as a feature, not a bug. I suspect that for many of the Republican policymakers who endorsed work requirements, the goal of such a policy isn’t genuinely to increase employment or remove support from only those who refuse to work. Rather, it is to redirect resources from lower-income Americans toward those at the top. And for that purpose, it is indeed well designed.
Matt Bruenig is the founder of People’s Policy Project.
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