If Trump Wants More People to Work, He Should Expand Medicaid Access, Not Shrink It

It doesn’t take a stable genius to understand that sicker people have a harder time finding and holding down a job.
January 12, 2018, 9:00pm

On Thursday, the Trump administration kicked off the New Year by inviting state Medicaid directors to experiment with work requirements, a move that would place 11 million people at risk of losing their health insurance if states nationwide took them up on their offer.

The Obama administration rejected such requirements, which were requested in the form of Section 1115 waivers, because they did not “support the objectives of the Medicaid program,” such as “strengthening coverage or health outcomes for low-income individuals.”


But Republicans made clear exactly what they think about those objectives last year, when they repeatedly tried to gut Medicaid as part of their failed attempts to repeal Obamacare. Now, the Trump administration appears to have found a way to overhaul the safety net program without a single vote.

Like drug testing people for food stamps, imposing work requirements on low-income people says more about who the Trump administration imagines these people to be and less about who they actually are.

“Most people who are poor do not choose to be poor. The image of a person in poverty who is listless or a person on Medicaid who is just enjoying being on the dole does not correspond to the facts,” says Don Berwick, a former administrator of the Centers for Medicare and Medicaid Services in the Obama administration.

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“When you look nationally, Medicaid beneficiaries who can work are working,” says Hannah Katch, a senior policy analyst at the Center on Budget and Policy Priorities. Nearly 80 percent of families receiving Medicaid have at least one family member who works. Only 13 percent of people who are able to work are not working, not trying to find work, or not in school, according to a Health Affairs analysis—but about 75 percent of that group cannot work because they are taking care of a family member.

Others are not working because there are few, if any, jobs to be had. While only ten states appear eager to force the poor to find jobs in order to hold onto their health insurance, many of those are also states where it is the hardest to find one. Take Kentucky for example. Eastern Kentucky has both the highest rates of unemployment in the state, which is in part a result of losing nearly 10,000 coal jobs since 2011, and the highest percentage of people enrolled on Medicaid.


There’s no argument that adopting work requirements will cause people to lose their health insurance. Five of the ten states that have applied for waivers admit that people will be kicked off of Medicaid within five years, including nearly 100,000 people in Kentucky. The other five haven’t even bothered calculating. Kentucky’s application was approved today, making it the first state allowed to impose a work requirement.

And while the letter from the Trump administration says it will “support state efforts to test incentives,” we already have a pretty good idea of what the results for the test of “taking healthcare away from the poor” will be.

The impact of withholding Medicaid coverage from a low-income person is as predictable as the impact of withholding a life-preserver from someone swimming in the ocean with an anchor tied around their waist. In 2014, researchers from the Centers for Disease Control and Prevention and the Urban Institute compared the health of low-income people in Medicaid expansion states with those in states that chose not to expand Medicaid to people who make 138 percent of the federal poverty line. (The Affordable Care Act made this an option.) The people who lived in non-expansion states had greater rates of high blood pressure, cancer, stroke, and emphysema, and were more likely to visit the emergency room.

“There is a very strong relationship between poverty and illness. Poor people tend to be sicker, and sick people tend to be poorer,” Berwick says. “That’s true in every nation on earth, and that’s true in our nation.”


It doesn’t take a stable genius to understand that sick people have a harder time finding and maintaining employment. The Ohio Department of Medicaid, for example, has shown that Medicaid coverage supports “employment and job-seeking.” If the Trump administration were serious about getting more of that 13 percent of people into the labor force, they would act to expand Medicaid access, not reduce it.

But the discussion about forcing people to work low-wage jobs in the name of personal responsibility is irrelevant, or, at the very least, is far from the spirit of the law. “It’s not about work,” Katch says. “It’s about making sure that people who have no other access to care can see a doctor when they need to.”

And that’s what one would imagine the Trump administration would be focused on, especially following a year that saw US life expectancy drop for the second-straight year for the first time since the early 60s and another report show that poor Americans live 10 to 15 fewer years than rich Americans.

Although then, the Trump administration would have to treat healthcare as a public good that everyone deserves, not because they are employed, but because, yes, Mr. Trump, even unemployed people are humans, too.

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