“The Trump administration’s action today is cruel,” said Democratic Congressman Frank Pallone Jr. of New Jersey. The new policy is “the latest salvo of the Trump administration’s war on health care,” according to a health care advocacy group. “The pain is the point” of the policy, wrote columnist and economist Paul Krugman.
They were attacking the Trump administration’s decision last week to allow states to impose work requirements on Medicaid beneficiaries. But far from being a “cruel” action designed to inflict “pain” on the vulnerable, the administration’s decision is completely reasonable.
Let’s start with the facts. First, the work requirements are targeted for able-bodied adults of working age. They do not apply to the elderly, to pregnant women or to the disabled. In addition, “work” is construed broadly to include community service, education, job training, volunteer service and treatment for substance abuse, among other potential forms of community engagement or self-betterment.
Furthermore, the administration is not forcing this policy on the states. Instead, states that wish to impose work requirements must seek permission from the Centers for Medicare and Medicaid Services. Currently, 10 states have done this. (The Obama administration denied such requests.) If the federal government gives approval, the states may make work activities a condition for Medicaid eligibility. But they can also be flexible in how far to go; for example, they might require work activities only as a condition for paying reduced co-payments (among the beneficiaries subject to them).
Take the case of Kentucky, whose proposal was just approved. As part of a five-year demonstration project, Kentucky’s work requirement exempts the groups mentioned above, as well as primary caregivers of a dependent, the medically frail or those with an acute medical condition that prohibits work, and full-time students. Beneficiaries subject to the requirement must complete 80 hours of work activities a month to remain eligible for Medicaid. Community service and job training qualify as work.
If these conditions don’t sound draconian, that’s because they aren’t.
Opposition to the very idea of making Medicaid benefits conditional on work might be understandable, given the history of the program. For most of its existence, Medicaid benefited groups of people who shouldn’t face such a requirement to receive health care — low-income single-parent households, the elderly and the disabled.
But the Affordable Care Act, signed into law by President Obama, changed this by allowing states to expand Medicaid eligibility to non-elderly, non-disabled adults (including those without dependents) with incomes up to 138% of the poverty line. As of last month, 32 states had carried out this expansion. According to the Kaiser Family Foundation, about 25 million Medicaid beneficiaries are covered due to the ACA’s expansion.
The ACA changed the very nature of the Medicaid program by expanding it to a large group of people who can reasonably be expected to work. Traditional opposition to Medicaid work requirements therefore needs to be re-examined. (The majority of the people who qualified for Medicaid because of its expansion are already working, demonstrating that work is not excessively onerous among many in this population.)