Republicans' Medicaid work requirements are already proving disastrous

Ohio recently released a glowing report about the results of its Medicaid expansion. The uninsured rate was cut by half. Low-income people have gotten healthier. Recipients say they have fewer financial troubles to worry about.

Ohio's experience with Medicaid expansion, which Gov. John Kasich enacted in 2013 over the objections of many of his fellow Republicans, is not an anomaly. Many states that expanded Medicaid have reported that low-income recipients are going to the doctor more and getting preventative treatments for chronic illnesses like diabetes and hypertension. All of this, plus state budgets haven't ballooned like critics said they would!

But it was too good to last.

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Early this year, the Trump administration signaled to states that it would allow work requirements in Medicaid for the first time, primarily targeting adults without (diagnosed) disabilities — a.k.a. the Medicaid expansion population.

A number of Republican-led states, with leaders who are no doubt stalwarts of a "pull-yourself-up-by-your-bootstraps" work ethic, hurried to apply to allow work requirements, with Kentucky being the first state approved. Indiana, New Hampshire, and Arkansas shortly followed, while a handful of other state applications (including one from Ohio) are pending, likely to soon be greenlighted.

Arkansas was the first state to actually implement the work requirement, which started this past June; the state is phasing it in, beginning with adults aged 30-49. These Medicaid recipients were to create an online profile and log at least 80 hours of work per month.

The results coming in from Arkansas are a good indicator of what is to come in the rest of the country. It isn't promising.

Of the approximately 44,000 adults who were subject to work requirements in July, just 2 percent, or 844 people, reported 80 hours of work. About two-thirds of the larger pool were exempt from the requirements (because they were already working or met another exemption), but a full 29 percent, 12,722 people, didn't report 80 hours and are at risk of losing health coverage.

All in all, over 5,000 people failed to meet the requirement for two straight months. If they fail to meet requirements for a third month — this August — they'll be kicked off Medicaid entirely.

There are multiple reasons why these requirements aren't working, and it all comes down to a misunderstanding of poverty — or more precisely, a willful ignorance of it.

To begin with, recipients are required to record their hours online, but Arkansas ranks 48th in the country for internet access. And that's regardless of the fact that, by definition, people on Medicaid are going to find it tough to afford an internet connection. Then there's also the difficulty of even signing into the Arkansas reporting website, which, inexplicably, is only open between 7 a.m. and 9 p.m. — i.e. work hours.

But these are procedural hurdles. Of greater concern is that the requirements fail to reckon with the reality of the low-wage labor market, where Medicaid recipients typically work — namely, that schedules are unpredictable. How is someone supposed to meet reporting requirements when they work 200 hours one month, but only 60 the following month? There are also few worker protections for low-wage workers, meaning they're more likely than a middle-income person to be out of a job if something goes wrong (like if their kid gets sick and they miss work). Then that person is out of their health insurance, too.

In fact, because thousands of people losing health coverage is a likely consequence of these requirements, a judge in Kentucky struck down the Medicaid work requirement in that state, arguing that Secretary of Health and Human Services (HHS) Alex Azar, "never adequately considered whether [Kentucky's program] would in fact help the state furnish medical assistance to its citizens, a central objective of Medicaid." That legal battle is still ongoing, but bet on the Trump administration pushing the requirements through.

To many Republicans (and some Democrats), poor people who lose their health care over "idleness" are probably receiving their just deserts. Or perhaps they believe in the softer side of the same bigotry and use flowery language like Centers for Medicare and Medicaid Services Administrator Seema Verma, who believes in "help[ing] [Medicaid recipients] achieve the dignity and self-sufficiency they deserve." Yet Verma's goal flies in the face of reality. Most people on Medicaid are already working, just in jobs that don't provide health care and that pay so little that they're eligible for Medicaid (expansion covers people that earn up to 138 percent of the federal poverty line, or $12,140).

Let's also circle back to those positive results from Medicaid expansion, which show people are getting healthier. Surely, better health enables more people to work, which is supposedly Republicans' end goal? Indeed, 83.5 percent of recipients surveyed in the Ohio report said that Medicaid coverage made it easier for them to work. The only caveat is that ideally this statistic wouldn't even matter — health care shouldn't be about enabling someone to work, but to live.

Here's the reality of low-wage work in the U.S.: The hours are long and underpaid, the schedules are volatile, and maybe one has a second (or third, or fourth) job to make ends meet. It's also more likely than a middle-class job to feature poor working conditions that could be unsafe. The truth is, working a low-wage job could sooner make you sick than healthy.

But if the health of the citizenry was the actual goal here, Republicans would be placing requirements on workplaces, not the workers toiling in them.