Jan 19, 2018
The Trump administration announced last week that it will allow states to deny Medicaid to people who are not meeting work or other daily activity requirements imposed by state officials. As my colleagues have shown, more than 6 million people are at risk of losing health insurance under the new policy. This makes it all the more infuriating that the Trump administration is making the Orwellian claim that its change will make people healthier.
In a series of tweets, Seema Verma, the Trump official who oversees Medicare and Medicaid, argued that work requirements will "improve health outcomes" and cause improvement in "mental and general health, and well-being." The administration's guidance allowing states to deny people Medicaid makes similar claims.
\u201c#Claimants who move off benefits and (re)-enter work generally experience improvements in income, socio-economic status, mental and general health, and well-being.\u201d #TransformingMedicaid \n\nhttps://t.co/TgmgCk6Bb2\u201d— Administrator Seema Verma (@Administrator Seema Verma) 1515677686
The administration points to two research reviews it says support its case for allowing state officials to deny Medicaid to low-income people not meeting state work requirements. In fact, neither of the studies say that imposing work requirements as a condition of receiving health care will improve health. Moreover, both of the studies rely heavily on research from countries with universal health coverage--that is, countries that provide health care and coverage to all of their people regardless of employment status and without imposing work requirements. In these countries, people are empowered to make work and education choices without being threatened with the loss of health insurance if the state doesn't like their choices.
In short, the reviews don't tell us anything about the impact of Medicaid work requirements on health. What they actually do tell us is the that relationship between health and employment is much more complicated than the administration suggests.
The most rigorous and recent of the two reviews found insufficient or inconsistent evidence that employment was beneficial for general health, except for depression. The authors also cautioned that selection effects--the fact that more healthy people are more likely to work--may have caused an "overestimation" of their findings that work was beneficial for depression. In theory, one could conduct a demonstration study that denied employment to some people while providing it to others in order to isolate the causal effects of employment on health. But, as the authors note, this would be unethical.
The older and less rigorous of the two reviews, a 2006 evidence review commissioned by the United Kingdom's Department of Work and Pensions, concludes that "the balance of the evidence" shows that work is "generally good for health and well-being, for most people." But it goes on to detail what it calls "major provisos." These include that "health effects depend on the nature and quality of work" and its "social context," and that "jobs should be safe and accommodating." The more rigorous review makes a similar point and notes research concluding that "low-quality jobs can lead to reduced health, while high-quality jobs can lead to improved health."
These findings about how low-quality jobs can negatively impact health are particularly relevant for Medicaid beneficiaries. As researchers at the Kaiser Family Foundation have documented, most non-elderly Medicaid enrollees (who do not also receive SSI disability benefits) are employed, but typically in poorly compensated jobs that do not offer health insurance. Among non-elderly Medicaid enrollees who are not employed, physical and mental health impairments are common.
\u201cIf we truly care about able bodied, working age adults on Medicaid, then we have a responsibility to help them rise out of poverty. \n\nhttps://t.co/0cXxSyAmQF\u201d— Administrator Seema Verma (@Administrator Seema Verma) 1516220652
If the state officials and the administration want to improve health and well-being, they should offer real help with finding well-paying, safe, and accommodating work to all Medicaid enrollees, but on a voluntary basis. This help should include child care assistance and other work supports. But allowing state officials to coerce people to take any job--or work even more--under threat of losing their health insurance takes away people's agency and will cause far more harm than good.
Finally, if the administration is serious about improving the health of working-class people, then it should stop rolling back important labor standards and worker protections. And it should get serious about improving job quality, including by raising the minimum wage as President Trump made a campaign promise to do.
Bottom line: All the happy Orwellian Twitter talk from Trump officials won't change the fact that their policy will hurt millions more than it will help.
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