Written by Dao Le
For the past five decades, Medicaid has provided health insurance for millions of Americans. Enrollment has increased from just 4 million in 1966 to over 74 million by the end of 2017 [1]. Though the program experienced rapid expansion during the Obama presidency, the Trump administration is currently proposing a work requirement for Medicaid recipients. To understand the implications of a work requirement, it is important to know the original goals of Medicaid as well as how the program was handled under both the Obama and Trump administrations.
Medicaid was signed into law by President Lyndon B. Johnson in 1965. It is an unfunded mandate, meaning that states are mostly responsible for funding the program; if a state refuses to fund the program, it loses funding from the federal government. Therefore, Medicaid is technically optional for states, though choosing to opt out can be harmful for them. The program was originally only available for those receiving cash assistance, but it now includes low-income families, pregnant women, people with disabilities, and people with long-term illnesses [2]. Medicaid was only a small fraction of what the Johnson administration deemed “the Great Society,” a domestic effort to create more equitable conditions for all Americans. Medicaid was intended to alleviate some healthcare-related financial burdens for low-income people to improve the health and productivity of the nation as a whole [3].
Under the Affordable Care Act (ACA), the Medicaid eligibility requirements were expanded to cover more Americans who did not qualify for the program beforehand. The ACA expansion allowed those who make under 138% of the federal poverty level, which is $15,417 per person, qualify for Medicaid benefits [4]. Before the expansion, barely any individuals or families earning income above the federal poverty level received Medicaid coverage [5]. Though not all states enacted the expansion, there was still a 50% increase in healthcare coverage for childless adults and a reduction in the proportion of uninsured individuals in the U.S. [6]. But how did the expansion affect worker productivity? A study published in May 2017 showed that there was no significant increase in work effort after the expansion [6]. This does not support President Johnson’s vision of a more productive society as a result of increased healthcare coverage.
In opposition to the ACA expansion, the Trump administration is proposing a work requirement, which would surely decrease the number of Americans who qualify for Medicaid. The administration credits studies with “strong evidence” that unemployment causes people to have poor health to justify this decision [7]. One mustn’t forget, however, that observational studies cannot prove causation. It is possible that unemployment causes people to have poor health, but in reverse, it is also probable that poor health causes unemployment or that unemployment and poor health just have a positive correlation without causation. Imposing a work requirement may harm low-income people currently looking for work and people who have chronic conditions or other serious problems that are not considered disabilities [8]. While the Trump administration believes it is improving the nation’s health by encouraging people to work, it is actually preventing vulnerable people from receiving necessary healthcare. As important as productivity is, it should not come at the expense of vulnerable Americans.
References
1. November 2017 Medicaid and CHIP Enrollment Highlights.” Medicaid.gov. https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html. Accessed 27 January 2018.
2. “History.” Centers for Medicare and Medicaid Services. https://www.cms.gov/About-CMS/Agency-information/History/. Accessed 27 January 2018.
3. “President Lyndon B. Johnson outlines the goals of ‘the Great Society’ in his 1965 speech.” New York Daily News. http://www.nydailynews.com/news/politics/lbj-outlines-goals-great-society-1965-article-1.2064026. Accessed 27 January 2018.
4. “Affordable Care Act Medicaid Expansion.” National Conference of State Legislatures. http://www.ncsl.org/research/health/affordable-care-act-expansion.aspx. Accessed 27 January 2018.
5. Paradise, Julia. “Medicaid Moving Forward.” The Henry J. Kaiser Family Foundation. https://www.kff.org/health-reform/issue-brief/medicaid-moving-forward/.Accessed 27 January 2018.
6. Kaester, R., Garrett, B., Chen, J., Gangopadhayaya, et al. 2017. Effects of ACA Medicaid Expansions on Health Insurance Coverage and Labor Supply. Journal of Policy Analysis and Management. 3: 608-642.
7. “Trump to let states require employment for Medicaid.” BBC. http://www.bbc.com/news/world-us-canada-42651541.Accessed 27 January 2018.
8. Tipirneni, R., Goold, S.D., Ayanian, J.Z. 2017. Employment Status and Health Characteristics of Adults with Expanded Medicaid Coverage in Michigan. JAMA Internal Medicine. 318(22): E1.