The Evidence and the Courts Agree: Work Requirements Threaten Medicaid Enrollees’ Health and Well-Being

Leah H. Keller, Guttmacher Institute and Adam Sonfield, Guttmacher Institute

Since entering office, the Trump administration has sought to undermine Medicaid’s role in helping millions of people access affordable and high-quality coverage and care. One main strategy has been by encouraging states to apply for "waivers" of federal law to institute work requirements, which would make Medicaid coverage dependent on one’s ability to engage in work, educational pursuits or other activities for a certain number of hours per month. Work requirements are often enforced through lockout periods, in which enrollees lose their coverage if they are unable to comply with the requirement or properly document their compliance.

The administration and conservative state policymakers have pursued these restrictions despite clear and accumulating evidence that they are ineffective or even counterproductive at their purported goals. More so, work requirements pose substantial dangers for Medicaid enrollees’ health and economic well-being, and more specifically for their sexual and reproductive health and rights. However, the courts have so far paid heed to this evidence and repeatedly rejected Medicaid work requirements.

Why Work Requirements Are Harmful

Proponents of work requirements argue that requiring people to work will somehow make them healthier and more self-sufficient. This premise ignores the reality of the Medicaid program and the people it serves.

First, though work requirements purportedly aim to encourage employment, most adults on Medicaid who are able to work do so, and those who are not working have good reasons: having an illness or disability, taking care of their home and family, going to school, being unable to find a job or being already retired from the workforce. Moreover, having a job does not by any means guarantee access to affordable health insurance: Just 30% of workers with incomes below the federal poverty level are even offered employer-sponsored insurance, and many of them cannot afford the premiums. Furthermore, work requirements are administratively complex to track and enforce, and simple mistakes by enrollees or the state can lead to loss of coverage even among enrollees who are in fact working.

Additionally, work requirements and lockout periods could drastically impede access to high-quality sexual and reproductive health care. Respondents who are unable to satisfy the enrollment requirements may repeatedly gain and lose coverage, which can jeopardize enrollees’ health by forcing them to forgo or delay care and undermining their relationship with their providers. It also provides potentially coercive financial incentives for Medicaid enrollees to choose long-term or permanent contraceptive methods because they are worried they may only have coverage for a short period of time.

Arkansas became the first state to implement a Medicaid work requirement in 2018. Although the Arkansas waiver was blocked by a federal court the following year, it provides an illuminating case study of the policy’s impact. Researchers found that none of the purported benefits of work requirements were achieved: In the six months following implementation, health insurance coverage fell significantly, while the state employment rate did not increase. Though approximately 95% of people subject to the work requirement satisfied the criteria or qualified for an exemption, the research shows that many who lost coverage found the requirements to be burdensome and confusing. The waiver did not help people get jobs or job training, but rather pushed them out of Medicaid.

Taking It to Court

Despite the arguments and evidence against Medicaid work requirements, the Trump administration has pushed ahead. As of August 2019, 16 states had applied for a waiver to impose a work requirement on at least some adult Medicaid enrollees, and the Centers for Medicare and Medicaid Services (CMS) had approved nine of those requests. Of those, five have not yet been implemented and just one state, Indiana, has a work requirement currently in effect, with lockout periods for failure to document compliance slated for early 2020.

Federal court action is the main reason that more states do not have work requirements in effect. In June 2018, a federal district court judge for the District of Columbia sent Kentucky’s work requirement—the first approved in the country—back to CMS for review, noting that the agency had not adequately considered the impact of the policy on Medicaid enrollees. In 2019, the same judge rejected a revised version of the Kentucky waiver and additional waivers from Arkansas and New Hampshire on similar grounds, meaning that none of the three states has a work requirement currently in effect. Evidence from Arkansas showing the harm of these policies has played a major role in the court cases and in the broader push-back against implementing them.

Why Medicaid Coverage Matters

The fight over work requirements and other Medicaid eligibility restrictions impacts the lives of millions of people. Medicaid provides health coverage for one in five people in the United States. The program covers a disproportionate share of marginalized women, including those who are in poor health, low-income, single parents, have disabilities or are women of color. In 2017, for example, it covered 50% of reproductive-age women (aged 15–44) nationwide with incomes below the federal poverty level, and 62% of black women in that income group.

More specifically, Medicaid is the central U.S. program for ensuring that people with low incomes have coverage for and access to reproductive health services, including family planning, pregnancy-related care, STI testing and treatment, cervical cancer–related care and services to address intimate partner violence. It does so by covering office visits (including preventive, prenatal and postpartum visits), pharmaceutical products (such as contraceptive drugs and devices), vaccinations (such as for the human papillomavirus), screening and testing services (such as Pap and STI tests), treatment services (ranging from antibiotics for chlamydia to radiation therapy for cancer), and counseling and referral (including for non-medical support services). Medicaid alone accounts for three-quarters of all public dollars spent on family planning in the United States and covers half of all U.S. births.

Medicaid has also demonstrated long-term health and financial benefits. Studies on the impact of Medicaid expansion under the Affordable Care Act and other efforts to increase Medicaid coverage have found that new enrollees report improvements to their overall health status, reduced credit card and medical debt, less difficulty paying bills and more money left over to spend on other necessities. This makes sense, given how affordable health care helps people address chronic and acute health issues that can interfere with their ability to work, study or care for others. Similarly, decades of research and women themselves say that family planning services help them to complete their education, get and keep a job, and take care of themselves and their families.


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