Medicaid work requirements: Where do they stand after the blue wave?

The 2018 midterm elections have dealt a significant setback to President Trump’s agenda in the legislative arena.

However, there are still many ways for the Trump administration to keep swinging away at the Affordable Care Act. One particularly effective unilateral instrument is the regulatory process – that is, the implementation of statutory law by executive agencies.

This may prove particularly consequential for Medicaid, the health coverage program for those with low incomes or disabilities. One particular area of attention for scholars like me is so-called community engagement or work requirements for Medicaid beneficiaries. These mandates generally require beneficiaries to conduct work-related activities or lose coverage.

While still in litigation, the Trump administration has indicated its strong commitment to moving forward with these efforts.

Helping individuals leave poverty is a worthwhile cause. As someone who studies health policy, I am concerned, based on research that others and I have conducted, that the focus of the Trump administration is misplaced. Indeed, their actions run counter to a broad scholarly consensus which universally emphasizes the benefits of health coverage. Most critically, they may disproportionately affect populations with vulnerabilities.

Work for coverage: What the evidence from welfare reform tells us

Work requirements have been implemented in a variety of public assistance programs outside of Medicaid. They have been featured most prominently in the Temporary Assistance for Needy Families program, or what Americans generally refer to as “welfare.”

When President Clinton and a Republican Congress “ended welfare as we know it” in 1996, they imposed strict work requirements and time limits for beneficiaries. The resulting changes can only be described as transformational. Importantly, they include a dramatic decline in the nation’s welfare case load.

Many people on Medicaid work, and many of those who do not wish they could find a job. Zoran Orcik/
Proponents of work requirements have hailed these developments as vindication of the policy. More deliberate assessments, however, have raised questions about this interpretation.

For one, there is strong evidence that a significant reduction in caseload was a result of the strong economy in the late 1990s. The reduction also coincided with the expansion of the Earned Income Tax Credit, which made work more profitable for low-income earners. Additionally, a major portion of the reduction of the welfare load has been the result of eligible individuals merely being diverted from the program.

When it comes to the experience of people who benefit from Medicaid, more causes for concern emerge. Indeed, most employment and income gains have proven ephemeral.

Individuals who were subject to work requirements generally found only entry-level, low-paying jobs without benefits.

Moreover, employment is often impermanent and therefore highly unstable.

Critically, beneficiaries have also failed to transition into better-paying jobs over time. As a result, they continue to struggle with housing and food security.

Studies have found no hard evidence for sustained reductions in poverty.

And certain populations faced particularly negative impacts. These include those with significant employment barriers such as chronic health conditions, low job skills, and low education status.

Minorities appear to also be disproportionately affected. The same holds for those suffering from addiction or domestic violence.

Perhaps of greatest concern is evidence that for a significant portion of those beneficiaries forced off public assistance the result has been a slide into deep and persistent poverty.

Work requirements and the Trump administration

Pres. Trump speaking at a rally in Wilkes-Barre, Pennsylvania, Aug. 2, 2018. Evan El-Amin/
Since taking office, the Trump administration has sought to aggressively introduce work requirements into the Medicaid program. It has argued that doing so would “put beneficiaries in control with the right incentives to live healthier, independent lives.”