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A work requirement for Medicaid recipients? It doesn’t make sense

REUTERS/Jim Bourg
Medicaid has broad bipartisan support and effectively delivers health care and financial protection to our most vulnerable citizens.

On March 12, three members of the Minnesota House of Representatives introduced a bill that would — for the first time ever — impose work requirements on adults who receive Medicaid, the public insurance program for low-income populations. Health policy experts agree that adding work requirements to Medicaid would increase uninsurance rates. Imposing work requirements does not make sense for Minnesota, and both liberals and conservatives should oppose the idea.

Ezra Golberstein

The Affordable Care Act allows states to expand their Medicaid programs to cover all adults whose incomes are below 138 percent of the federal poverty line ($12,140 for a single person, $25,100 for a family of four), with the federal government paying most of the costs. This Medicaid expansion has been a key driver of record-low uninsurance rates in Minnesota and nationally. Medicaid covers nearly 1.1 million Minnesotans, approximately 40 percent of whom are non-disabled, non-elderly adults who would be affected by the proposed work requirements. Extensive research shows that Medicaid expansions protect households from financial ruin, improve access to health care, and improve mental health for low-income adult populations. Notably, recent Medicaid expansions caused little-to-no reduction in people’s employment.

A recent article in the Journal of the American Medical Association argues that Medicaid work requirements are a solution to a nonexistent problem. According to the Kaiser Family Foundation, 60 percent of the non-disabled, non-elderly adult Medicaid population already works either full- or part-time. Only 6 percent of this population is not working and not in a situation that would exempt them from work requirements (being in school, caregiving, or having serious health problems that prevent work), and that 6 percent includes those who are already actively looking for work.

Undermining the safety net

Another concern is that work requirements would undermine Medicaid’s role as a safety-net insurance program. The House bill calls for monthly verification that work requirements or exemptions are being met. Surely, these administrative requirements would cause qualified individuals to fall through the cracks and lose coverage, which is not how safety nets should work. Furthermore, we should promote employment in a way that matches people’s skills with jobs. The bill states that someone must “accept any bona fide offer of suitable employment” to maintain Medicaid coverage. This may lead people to land in jobs that are poor matches for them, their families, and possibly their employers. That is not what pro-employment policy should look like.

Liberals will oppose Medicaid work requirements for a variety of reasons related to a general philosophy that government bears responsibility for providing insurance to low-income populations. But why should conservatives oppose work requirements for Medicaid? For one, enforcing and administering work requirements would be quite costly for the Department of Human Services (DHS). This would entail monitoring all adults for work requirements and adjudicating cases of whether or not someone meets an exemption, not to mention the numerous inevitable appeals. It would hugely increase the department’s bureaucracy. Considering that relatively few people would be directly affected by the proposed work requirement, these bureaucratic costs may not be worth it.

Conservatives may also balk at the way this bill would empower DHS bureaucrats who would make judgment calls about each individual’s ability to work, whether individuals meet a “good cause exemption,” what activities count as “community service,” and more. This scenario should not appeal to conservatives who oppose paternalistic and bloated government bureaucracies. Contrast that with the current scenario, where DHS plays a more limited role. If your income is below the threshold then you are eligible, and you can decide whether to enroll in Medicaid. That’s far simpler than adding work requirements to Medicaid.

Medicaid is efficient and enjoys bipartisan support

To be sure, the bill’s authors may simply want to shrink the Medicaid program. I disagree with that goal. Medicaid has broad bipartisan support and effectively delivers health care and financial protection to our most vulnerable citizens. Increasing employment and overall well-being for low-income adults covered by Medicaid is a noble bipartisan goal, and we could suggest reasonable policy approaches to achieve it from across the political spectrum. Imposing work requirements for Medicaid is not one of them.

Medicaid is a health insurance program, not an employment-promotion program. We should continue to ensure that Medicaid delivers quality health care to low-income households as efficiently as possible, rather than introduce new and expensive red tape to address a problem that may not even exist.

Ezra Golberstein, Ph.D., is an associate professor of health policy at the University of Minnesota.

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Comments (13)

  1. Submitted by Frank Phelan on 03/27/2018 - 09:43 am.

    Ignore That Man Behind the Curtain

    A Medicaid work requirement, like drug testing of other public assistance programs, is all about the politics of division, and creating a smoke screen. “Ignore the huge permanent tax break for the wealthy behind the curtain, look at how I’m spending a dollar to save you a dime.”

    It’s so easy to comfort the comfortable and afflict the afflicted. Much easier to pick on society’s lowest. So tempting, even for a Christian like me.

    • Submitted by Karen Sandness on 03/31/2018 - 12:07 pm.

      Exactly!The entire thrust of

      Exactly!

      The entire thrust of Republican social policy since the Reagan era has been to create resentment among the middle class by spreading the lie that there are vast groups of able-bodied slackers getting rich off social programs and that the main purpose of these programs is to motivate people to vote for Democrats.

      They compound the lie by claiming that these poor people are bankrupting the country.

      In fact, the Department of “Defense” and military expenditures hidden in the Department of Energy, Homeland Security, and Veterans’ Affairs account for over half the discretionary budget, the part that your annual federal income taxes pay for. That doesn’t even include the so-called “black budget,” which is not public information, but which includes most covert spying and intelligence activities.

      Just as an example of going after the wrong targets, the much maligned food stamp (SNAP) program is about 2% of the federal budget, and among the recipients who are not retired or disabled, most are employed. The Environmental Protection Agency is less than 1% of the federal budget. The Corporation for Public Broadcasting costs as much as two days of the Iraq War.

      So why the lies about “lazy poor people bleeding the country dry”?

      Paradoxically, one problem is that federal benefits are stingy compared to the social benefits in other countries. People who are still struggling financially (and for good reasons, such as health problems, expensive repairs, or other unforeseen expenses, or low wages) see their neighbors who are only a bit less well off getting benefits while they themselves are ineligible. This is especially true of health insurance or subsidized daycare. It is easy to create resentment on this basis.

      If everyone were eligible for health care that was low-cost or free at the point of service, this resentment wouldn’t exist.

      But the overriding reason for the demonization of the poor is that we have a bought-and-paid-for government. Wealthy and powerful people can make themselves even more wealthy and powerful by bribing (because that’s what it really is, even if the donors and recipients refer to it as “buying access”) politicians to give them no-bid contracts, fund fantasy weapons systems, keep drug prices high, keep insurance private, keep weapons of mass murder in the hands of individuals, ditch the environmental laws that have improved air and water quality in my lifetime, or defund any form of transportation that doesn’t involve rubber tires on asphalt at some point. That’s just the beginning of the list, and many Democrats are just as bad as the Republicans in this respect.

      If poor people and middle class people ever became (to use the currently popular expression) “woke” and joined forces to demand an end to corruption and the beginning of measures to improve everyone’s quality of life, the gravy train for the already-affluent would end.

      That’s why the right wing’s divide and conquer tactics are relentless–and sadly effective among people who don’t bother to seek out the truth.

      • Submitted by Misty Martin on 04/03/2018 - 11:49 am.

        Karen, THANK YOU!!!!!!!!!!

        I especially LOVE your 8th paragraph (I believe) that states: “If everyone were eligible for health care that was low-cost or free at the point of service, this resentment wouldn’t exist.”

        I still maintain that President Obama really desired that very thing, and sought to bring it about, or get as close to it as he could, but his hands were tied by those who opposed the Affordable Healthcare Act in the first place, and then, well, we all know the rest.

        I really appreciate the way you stated things. It really can’t get any clearer than what you penned down. Thank you.

  2. Submitted by Dennis Wagner on 03/27/2018 - 11:51 am.

    Rights vs. Responsibilities

    There are a couple key questions that should have been addressed. Where do your responsibilities start? Example: The argument was made about fitting people to their skill set. How about folks taking personal responsibility for themselves and their families? Many of us haven’t worked in our “dream” jobs for much of our lives, why? Because it didn’t pay the bills and provide for the family, we took some pretty nasty jobs, way below or outside our skill set, we took responsibility for our own outcomes. Arguments are made that someone needs to take care of the kids, there are lots of our neighbors, and self included that had dual income families and took care of our kids, yes its a struggle, but, we took responsibility. So the big question, when are folks responsible for their outcome? Or is it, that I am responsible for mine and theirs, and they have a right for me to be responsible for theirs? The 2nd part of the conversation that should be addressed, if folks live an unhealthy life style, they will be a burden on the medical system, i.e. they have a right to live they way they chose, but evidently they have no responsibility to not be an additional burden on the system, but everyone else has a responsibility to pay for their unhealthy life style consequences?

  3. Submitted by Curtis Senker on 03/27/2018 - 12:04 pm.

    “…government bears responsibility for providing insurance to low-income populations.”

    The Constitution disagrees. For this reason alone, Medicaid should be restricted as much as humanly possible.

    No one I know says Americans that are disabled, through no fault of their own, should not have the support of other Americans. But non-citizens, and Americans who lead feckless lives enjoy no such accomodation.

    • Submitted by Pat Terry on 03/27/2018 - 01:48 pm.

      Humanly possible

      The constituion doesn’t disagree – it doesn’t say one way or another. There is no constitutional prohibition on the government providing insurance to low-income people.

      Is it really too much to ask that all humans – low income, disabled, even feckless – have access to affordable healthcare? Can’t we do everything humanly possible to help people out?

      • Submitted by Curtis Senker on 03/27/2018 - 03:33 pm.

        “The powers not delegated to the United States by the Constitution, nor prohibited by it to the states, are reserved to the States respectively, or to the people.”

        Health insurance, or care is not delegated to the United States by the Constitution. If the various States wish to offer it to everyone, they can. So your argument belongs in St. Paul.

        • Submitted by Pat Terry on 03/27/2018 - 11:16 pm.

          Completely wrong

          That comment reveals a common, but painfully ignorant and totally erroneous understanding of how the constitution works. You can’t just apply a 3rd-grade legal analysis, read through the text of the document and say “well, its not in there, so its not constitutional.”

          The framers contemplated that, obviously, issues would come up that could not be decided by the constitutional text itself. So they created a court system. And that court system has been weighing in on the constitionality of government actions for 200+ years. And over that time, the Supreme Court has repeatedly held (Medicare, Medicaid, the ACA, etc.) that providing health insurance/healthcare is, in fact, within the delegated powers of the United States government.

  4. Submitted by Matthew Steele on 03/27/2018 - 01:40 pm.

    “…government bears responsibility for providing insurance to low-income populations.”

    Just low-income? I consider myself politically moderate, but it seems ridiculous we haven’t followed nearly all other civilized nations in ensuring that everyone has access to healthcare. Medicare for all.

  5. Submitted by Kathie Noga on 03/27/2018 - 03:43 pm.

    Medicaid Work Requirement

    I am one of those individuals which would be greatly effected by this stupid idea. For one thing it is very hard to look for work when you have to do community service. Also if they really want to help us get work they should fund public transit so we can take jobs on suburbs not on the bus line. This is one of our greatest barriers to employment. When you have to take 3 to 4 buses to get to work, this is totally crazy. Often you wait in the cold without a bus shelter for more than a half hour. If you have asthma you simply can’t be doing this in Minnesota cold weather. Forty percent of jobs are temporary and we need the health insurance because agencies often have assignments which are 2 to 3 months. It takes that long to get health insurance from agencies. Some of us need health insurance to work. The means test is very costly. I know I have a degree in Social Work and know how costly it is to do it for food stamps and GA and other programs. To really save money, I am in favor of single payer health insurance. Everyone would be covered then. To really save money, do $1,000 guaranteed income for everyone. You would not need the means test for anything. I could actually do what I am good at: tutoring children in writing skills. I could put a computer in my apartment and write books and bring in more income to my household. This would put more money into the economy.

  6. Submitted by Bill Willy on 04/03/2018 - 03:23 pm.

    Is that ALEC over there?

    Ezra Golberstein said, “On March 12, three members of the Minnesota House of Representatives, introduced a bill that would — for the first time ever — impose work requirements on adults who receive Medicaid, the public insurance program for low-income populations.

    I agree with everything Mr Golberstein said, with the exception of that . . . And it’s not that I disagree that members of the House introduced the bill, but I disagree that they were introducing it on behalf of their constituents (you know . . . those Minnesotans they’re supposed to be representing in our “representative democracy”?), but on behalf of the American Legislative Exchange Council:

    “Through the corporate-funded American Legislative Exchange Council, global corporations and state politicians vote behind closed doors to try to rewrite state laws that govern your rights. These so-called ‘model bills’ reach into almost every area of American life and often directly benefit huge corporations.

    “In ALEC’s own words, corporations have ‘a VOICE and a VOTE’ on specific changes to the law that are then proposed in your state. DO YOU? Numerous resources to help us expose ALEC are provided below. We have also created links to detailed discussions of key issues, which are available on the left.”

    http://www.alecexposed.org/wiki/ALEC_Exposed

    This is a link to a web page in the “model-policy” section of the ALEC web site. The title of ALEC’s “model legislation” for this particular “issue” is “Self-Sufficiency in Medicaid Act”:

    http://www.alec.org/model-policy/self-sufficiency-in-medicaid-act-2/

    Here’s a link to HF 3722, the Minnesota House version of that “model legislation”:

    http://www.revisor.mn.gov/bills/text.php?number=HF3722&session=ls90&version=latest&session_number=0&session_year=2018

    And here’s a link to SF 3611, the Minnesota Senate’s version:

    http://www.revisor.mn.gov/bills/text.php?number=SF3611&version=latest&session=ls90&session_year=2018&session_number=0

    Here are the members of the Minnesota House who are listed as the authors of HF 3722:

    Representative Kelly Fenton (R) District: 53B (lead author)
    http://www.house.leg.state.mn.us/members/members.asp?leg_id=15434

    Representative Kurt Daudt (R) District: 31A
    http://www.house.leg.state.mn.us/members/members.asp?leg_id=15345

    Representative Joyce Peppin (R) District: 34A
    http://www.house.leg.state.mn.us/members/members.asp?leg_id=12273

    Representative Cindy Pugh (R) District: 33B
    http://www.house.leg.state.mn.us/members/members.asp?leg_id=15411

    Representative Josh Heintzeman (R) District: 10A
    http://www.house.leg.state.mn.us/members/members.asp?leg_id=15435

    Representative Peggy Bennett (R) District: 27A
    http://www.house.leg.state.mn.us/members/members.asp?leg_id=15430

    Representative John Poston (R) District: 09A
    http://www.house.leg.state.mn.us/members/members.asp?leg_id=15471

    Here are the members of the Minnesota Senate who are listed as the authors of SF 3611:

    Senator Mark Johnson (R) District 01 (lead author)
    http://www.senate.mn/members/member_bio.php?leg_id=15485

    Senator Michelle R. Benson (R) District 31
    http://www.senate.mn/members/member_bio.php?leg_id=15322

    Senator Julie A. Rosen (R) District 23
    http://www.senate.mn/members/member_bio.php?leg_id=10803

    Senator Andrew Mathews (R) District 15
    http://www.senate.mn/members/member_bio.php?leg_id=15491

    Senator Paul J. Utke (R) District 02
    http://www.senate.mn/members/member_bio.php?leg_id=15493

    If you’re not sure and would like to know if any of those people represent you, here’s a link to the MN Legislative Coordinating Commission’s, “Who represents me?” page:

    http://www.gis.leg.mn/iMaps/districts/

    Just enter your address, city, state and zipcode.

    Clicking on the legislator’s photo will open their web page which contains contact and other information in case you’d like to contact them to let them know what you think of the bill and, if you’re curious enough, what they think about ALEC; whether or not they’re an ALEC member; whether or not they’re aware of ALEC’s “Self-Sufficiency in Medicaid Act” model legislation; and, most importantly, whether they’re representing YOU of ALEC.

    Regardless of “party affiliation” or “political persuasion,” I would recommend that the voters of Minnesota NOT VOTE FOR ANY LEGISLATOR who is either a member of ALEC or simply goes along with whomever in their party’s leadership introduces and recommends they support ANY version of ANY “model legislation” that originates with ALEC.

    I recommend that we ALL vote for people who represent US and US only.

    You know . . . We the People?

  7. Submitted by Bill Willy on 04/03/2018 - 06:54 pm.

    The (intentional) wrong tree barkers

    Here’s a short list that compares some of the yearly per capita costs of health care in a few of the countries in the “developed world” . . .

    Australia: $4,708

    Canada: $4,753

    Denmark: $5,205

    Finland: $4,033

    France: $4,600

    Germany: $5,551

    Iceland: $4,376

    Ireland: $5,528

    Israel: $2,822

    Italy: $3,391

    Japan: $4,519

    New Zealand: $3,590

    Norway: $6,647

    Sweden: $5,488

    Switzerland: $7,919

    United Kingdom: $4,192

    United States: $9,892

    https://en.wikipedia.org/wiki/List_of_countries_by_total_health_expenditure_per_capita

    If the authors and supporters of the “Medicaid Work Requirement” bill are genuinely interested in bringing down the cost of their constituent’s health care they should start by asking themselves — and any impartial and informed people they can locate — one of the most basic questions there is:

    Why?

    Why is the cost of the health care in Canada $5,000 less per person per year than it is in Minnesota and the rest of America?

    Why is the cost of the health care in the UK $5,700 less per person per year than it is in Minnesota and the rest of America?

    Why are the health care systems in ALL of the countries listed above producing better health care outcomes (as in longer life spans and less chronic disease) than the American health care system is producing?

    And no . . . The answer is not, “Because of Obamacare and MNSure”: The same basic health care price disparity has been the case since the 1980s — the last time the price of health care in America was in-line with the price in the rest of the developed world.

    Any lawmaker who thinks attaching a “work requirement” to any Medicaid recipient’s life is going to do ANYthing to make that person’s life or health better, or that it would do ANYthing to “bring down the cost of health care,” is either deeply deluded, fiscally incompetent, blowing pure cheap political smoke, or working on behalf of one of the world’s most profitable businesses: American Health Care, Inc..

    All these alleged “money saving measures” are nothing but a diversion . . . Nothing but time and money wasting moves designed to “cloud THE issue” (the outrageous PRICE of health care) and protect the business-as-usual rails on which the for-profit health care industry gravy train keeps rolling.

    The endless blaming of the Affordable Care Act and “big government” is nothing but a way of keeping people from asking and answering that most basic health care question: Why does American health care cost an average of $5,000 more per Minnesotan than it costs those who live in every other developed place on the planet?

    To propose that people living near, at, or below the poverty level should be forced to jump through more hoops than they already do to be “granted” access to health care (in the richest country on Earth!) instead of asking and answering that question and DOING something about it is beyond “morally bankrupt” and obscene.

    When our elected representatives do nothing to answer that question and avoid taking any meaningful steps to implement a solution, they are putting the financial interests of those causing the problem ahead of the health and financial interests of their constituents and (almost) all other Minnesotans.

    They’ve been playing this deadly, financially devastating game far too long, they need to be removed from office as soon as possible and they need to be replaced with Minnesotans who will actually ask, answer and take real action on that question.

    If a country right on our northern border can see to it that all their citizens have complete access to higher quality health care than Minnesotans do — and do it for $5,000 less per person per year — there’s no reason we can’t do the same.

    No reason other than our elected representatives REFUSING to allow it to happen.

    If your representative is refusing to allow that to happen they are NOT representing you and your family’s best interest. Far from it. They are doing nothing but continuing to insist that you and your family keep spending at least $5,000 per year more than necessary for something as basic and necessary as your health.

    Why would anyone vote for ANYone (Republican, Democrat, Independent, Whatever) who represents them like that?

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