When Stephen Pimpare learned last week that the Trump administration would begin allowing states to test establishing work requirements for Medicaid, which provides healthcare coverage for roughly one in five Americans, he was frustrated if not surprised.
“The constant strain of American political culture has been to internalize this idea that if you are poor it is a moral failing, rather than circumstances beyond your control,” says Pimpare, a University of New Hampshire professor and author of A People’s History of Poverty in America. As far back as the 1800s, he notes, poorhouses in major American cities including Chicago and New York imposed so-called work tests, where in order to demonstrate their “deservingness,” people would “have to carry rocks from one side of the yard to another and then carry them back again.” Up through the twentieth century — with the Reagan-era image of “welfare queens” sitting around the house collecting checks — and into the twenty-first, Pimpare added, “every argument in favor of work requirements is based on ignorance of the population that uses the program.”
In announcing new federal guidelines last week, Seema Verma, who heads the Centers for Medicare and Medicaid Services, said the goal is to move Medicaid recipients out of the program and into jobs with private insurance benefits. Seventy percent of respondents to a national Kaiser Family Foundation poll last summer said they supported work requirements for Medicaid. But in fact, 60 percent of Medicaid recipients of working age and without a qualifying disability already worked either part- or full-time as of 2016, according to another Kaiser study. Among Medicaid recipients who don’t work, roughly a third are ill or disabled, and another third are caretakers, according to Kaiser.
And New York City’s own experience with work requirements — most prominently for recipients of welfare benefits, as implemented under the Giuliani and Bloomberg administrations — indicates that trying to force the relatively few Medicaid recipients who can work but don’t to enter the workforce, or risk losing benefits, increases the risk of collateral damage for all recipients.
Sanctions for those who can’t provide proof of employment, says Legal Aid Society supervising attorney Kenneth Stephens, “vastly increase the number of families at risk of homelessness, hunger, and the attending consequences of not having even close to enough money to live on. So if you are talking about adding on to that a denial of access to healthcare? Fill in the blanks.”
There is some evidence that work requirements can increase employment, at least in the short term. In 2016 the Center on Budget and Policy Priorities reviewed thirteen studies of work requirement programs across the country from the 1990s, after the Clinton administration implemented work requirements for cash and food assistance (and sanctions for noncompliance). A Portland, Oregon, program saw employment of welfare recipients increase 11.2 percent in its first two years, for example.
But those gains dropped off within five years. More importantly, the same report found that the jobs people entered weren’t high-paying enough to lift workers out of poverty.
“I just question whether we’re really tackling the biggest problem we are facing, which is structural issues in the lower-wage labor market,” says Elaine Waxman, a senior fellow in the Income and Benefits Policy Center at the nonpartisan Urban Institute. The fast-growing job markets, she points out, tend to be in industries like home care that are low-paying and don’t come with benefits or collective bargaining rights. “We’d all like a world where people don’t have to rely on a safety net. But we have to be realistic about the world of work we’re facing.”
Ten states, including Arizona, Arkansas, and Maine, have already requested waivers to impose Medicaid work requirements. Governor Matt Bevin of Kentucky announced last Friday that his state will be the first to do so, with a program that “incentivizes personal responsibility.” (He also praised the plan as fiscally responsible, though whether the state will actually save money once administrative costs are factored in is an open question.) In addition to 80-hour-per-month work or “community engagement” requirements (job search, job training, volunteer work, or school), qualified recipients will have to pay monthly premiums of $1 to $15 to the state. Recipients will also risk a multi-month suspension of benefits if they fail to quickly report income changes.
“Much of what worries us about the new plan is simply that it’s highly bureaucratic,” Rich Seckel, director of the Kentucky Equal Justice Center, tells the Voice. In Kentucky, more than half of residents receiving expanded Medicaid are already employed, though most work in jobs with fluctuating hours and incomes that would be difficult to report accurately. As of 2015, the top three industries for working Medicaid recipients in the state were food service, construction, and retail. “How would they even know if a change in their income would make them ineligible?” Seckel wonders.
“I am self-employed dry stone mason,” one anonymous Kentuckian wrote during an open comment period on that state’s proposal last summer. “My work or lack of work depends greatly on the economy.… Since I am self employed, I have no way of knowing what my monthly income will be, if any.” Fulfilling a short-term work or community service requirement would cut into his job hunting, he added.
Problems arose as well in New York City when Mayor Rudy Giuliani implemented the country’s largest “workfare” program, the Work Experience Program, in 1995. In order to receive cash assistance, New Yorkers without a job were required to work 35 hours per week — as janitors, as maintenance workers for the MTA, and in city parks. They received no pay other than their welfare benefits.
According to Stephens, recipients “would lose some or all of their meager subsistence benefits for something that could be as simple as missing a meeting because their kid was sick, or they went to attend housing court, or any of the numerous things that can happen in an individual’s life.”
Under Giuliani, the number of New Yorkers on welfare fell steeply, from 1.1 million to fewer than 500,000. By early 2010, that number hit 350,000. It has now rebounded slightly to 366,387 as of last November, after Mayor de Blasio restructured the program, replacing labor requirements with certification classes (GED, food handling, a commercial drivers license); college enrollment also qualifies. The Legal Aid Society has also successfully litigated to scale back sanctions.
Bronx resident Margarita Cruz, 49, is a member of the nonprofit Community Voices Heard, which formed in response to what it considered the modern-day slavery of workfare. Cruz participated in WEP as a subway cleaner starting in 2014 when her twin daughters were nine years old. In January 2017, she was finally hired by the MTA, albeit in an entry-level position.
Cruz tells the Voice that under workfare, the HRA initially “wanted the people to take whatever they were offering. And the jobs only last for three or four months and then you have to go back through the system.” During her three years on WEP, she says, “all the time I was trying to not be suspended, because then…I’m going to have problems with the rent and the food and everything.”
Pimpare, the UNH professor, predicts that efforts to implement work requirements for Medicaid will stall in the courts. Section 1115 waivers, which allow the federal government to approve pilot programs like this one, are required to help states further the goals of Medicaid, and as Pimpare says, “nowhere in the Medicaid statute does it say anything about ‘work’ being a goal.” Advocates in Kentucky are already threatening to sue before that state’s plan goes into effect in July (Bevin has responded with a fresh threat to shut down his state’s Medicaid expansion altogether), and the Southern Poverty Law Center is also planning to challenge the new federal guidelines.
Regardless, Hannah Katch, a senior policy analyst at the Center on Budget and Policy Priorities, warns against assessing these proposals in a vacuum. “I think it’s in the context of a consistent attack on the Medicaid program that we’ve seen over the last year,” she says. “We saw legislation in the House and Senate — that came very close to passing — that would have massively cut and radically restructured the financing of Medicaid. And I don’t think they’re done.”
If Kentucky can set a national example, so too can New York, argues Katie Robbins, director of the Campaign for New York Health, a coalition advocating for a single-payer statewide healthcare system. This April, the state assembly is expected to pass the New York Health Act for the third consecutive year. This would disband private insurance in New York State. Last year the bill came one vote shy of majority support in the Senate without any Republican endorsements. That holdout vote, Simcha Felder of Borough Park, is a Democrat who caucuses with the Republicans. Advocates are already canvassing his neighborhood this year, where a third of residents lived in poverty in 2015.
“His office has not responded positively — it’s very disappointing,” Robbins says of Felder. Still, Washington’s repeat attacks on Medicaid are only fueling the fire.
“I think it’s just another example of the kind of responsibility a state like New York or California has,” she adds. “To set the bar really high for the kind of healthcare program we really need.”