Ohio is now considering establishing work requirements for its Medicaid program. The Trump administration took steps last week to make this possible, issuing new guidelines for states. Notably, the new guidelines draw on provisions of the Affordable Care Act that were intended to help states expand Medicaid. In paving the way for restricting access to Medicaid, they pervert the intent of those provisions.
Requiring more Medicaid eligibles to work might sound like a sensible idea on the surface. Of course, it’s important to listen to the arguments of those who believe that many Medicaid recipients could work but don’t, or could find a way to pay for health insurance or secure it from an employer. There is room for legitimate debate on the foundations and goals of health care policy.
But these perspectives are wrong: the vast majority of Medicaid recipients cannot work; do work but are not eligible for health insurance; or cannot afford to pay for health insurance themselves. Many work for small companies that do not offer health insurance, or that offer insurance with cost-sharing arrangements that make them unaffordable to employees. Medicaid experts have determined that virtually everybody on Medicaid who can work, already does. According to the non-partisan and widely respected Kaiser Family Foundation, about 80% of adult Medicaid recipients are part of working families. Add to this data point the fact that many Medicaid eligibles work in some of the most difficult and underpaid industries. Many of them work multiple jobs. Most Medicaid eligibles who do not work are either disabled or have caregiving responsibilities. Forcing this last group to work, of course, has the result of pulling them from such responsibilities, with potentially negative consequences for those they care for. Ohio should support caregivers.
The key question is what the consequences will be from Medicaid work requirements. We know a bit from past policy efforts – especially with work requirements established by the Clinton administration for the Temporary Assistance for Need Families program – that the negative consequences of these policy efforts outweigh the positive. The picture with the current Medicaid work requirements now being discussed is no more more promising.
In issuing the new rules, Seema Verma, director of the Centers for Medicare and Medicaid Services (CMS), said, “Our fundamental goal is to make a positive and lasting difference in the health and wellness of our beneficiaries, and today’s announcement is a step in that direction.” But we know – empirically – that these policies will damage poor people’s health, making Verma’s larger goal transparent. This is not an attempt to increase the number of Americans who work, but a way to thin the Medicaid roles. The result will be more Ohioans whose health – and especially addiction and mental health – needs will go unmet.
The CMS rules do require that states must work with those being subjected to work requirements, by helping Medicaid eligibles (pregnant women, children, and the disabled excepted) find work or training to develop necessary skill sets. But CMS also forbids states from using Medicaid funds to pay for such “supportive services.” With history as our guide, the chances are low that Ohio will invest in a compassionate and well-designed program to support these individuals. They will be out of sight, out of mind.
Ohioans may not know how much heavy lifting Medicaid does in our state. Sometimes, especially when the media focuses on outliers, it’s easy to lose sight of exactly what the Medicaid population looks like. Kaiser provides a useful snapshot here, but the basic point is this: these are not people who have much room to maneuver. They are often on the edge of bankruptcy–the avoidance of which is one of Medicaid’s most important functions, with serious consequences for health. These people are not, as media representations sometimes suggest, a group that lives cushy lives off the government dole. Our Republican governor himself once knew this to be true, which is why he called the ACA’s Medicaid expansion, in 2013, “a matter of life and death.” As some Ohio physicians have attested, for many patients, it has been just that. I have consistently said that we should praise Kasich for his leadership on this issue (even as we take him on on others), and remember that he went to great lengths to expand Medicaid, even against the will of his party. But here again, our governor may have a short memory on this and we need to remember the population we are talking about, and what their lives are like. Kasich’s efforts expanded Medicaid to those individuals making up to 138% of the federal poverty level. That’s just under $17,000 a year.
While a handful of Ohioans will no doubt be swept into employment, accomplishing work requirement advocates’ ideological goal, the broader economic and health picture should drive our thinking about the wisdom of this policy approach. Under current arrangements, Ohio’s Medicaid program is an extremely good deal, with the federal government paying in about $1.65 for every dollar the state contributes–a generous federal matching rate that reflects Ohio’s lagging per capita income. These matching funds also constitute the largest influx of federal money to the state, employing thousands of Ohioans in health care and other caregiving jobs. If the injustice of stripping access to Medicaid from tens, if not hundreds of thousands of Ohioans is not enough to persuade lawmakers to reverse course, then Ohioans should be aware that when the thousands of people who stand to lose their Medicaid show up for care in emergency rooms, that care will be the most expensive and inefficient available, and 100% of cost will be picked up by hospitals and other providers, as well as–ultimately–Ohio taxpayers. There is also a paradox at work here for a policy proposal that supposedly champions increased employment: as uncompensated care rises among Ohio’s health care institutions, they will need to slow hiring. In other words, fewer jobs in Ohio’s currently booming health care sector is one of several likely outcomes.
CMS Director Verma and many Republicans claim that there is a correlation between health outcomes and employment status. This is a misreading. The more important point is that there is a correlation between economic security and wealth and health outcomes. New work requirements for Medicaid eligibles only makes good health policy if these Ohioans are going to be provided with good paying, stable, and respectable work. The wisdom of such a proposal is closely related to discussions about fair and livable wages since there is a point where working is simply not worth it, or where some Medicaid eligibles determine that caring for their children or family is not worth trading for a minimum wage job that will not even pay the rent or keep the heat on. The problem with Ohio adapting work requirements for Medicaid concerns the effects on those who will lose their Medicaid access when weighed against any benefits for the small segment of the population that will begin working. No doubt, some, especially in the conservative media, will spotlight the small percentage of Medicaid recipients who are pushed into the workforce as a result of these new rules. They will be, as they often do, missing the forest for a few trees.
The goal should be to make access to Medicaid as easy as possible for Ohioans. Cuts in the rolls may achieve partisan political goals, but are both unethical and short-sighted from the perspective of Ohio’s health profile, which Medicaid stabilizes at a very basic level, as one way of mitigating the consequences of massive inequality and racial injustice that fuels so much poor health in the state. There are likely to be legal challenges. There needs to be activism, too.
Daniel Skinner, Ph.D., is Assistant Professor of Health Policy in the Department of Social Medicine at Ohio University’s Heritage College of Osteopathic Medicine, in Dublin, Ohio. Follow him on Twitter at @danielrskinner