Give Medicaid Work Rules a Try — Carefully
Requiring some Medicaid recipients to work is not the worst idea to come out of Donald Trump's administration. It might nudge some beneficiaries toward more productive lives, and it could help subdue persistent sentiment that the program allows adults who should be working to get free health insurance at taxpayers' expense.
But these aspirations will not be realized unless there is strict oversight. If the federal government wants to allow states to require their Medicaid beneficiaries to work, then it also has to ensure that anyone truly unable to do so does not lose Medicaid.
These proposed rules -- essentially a waiver that would allow states to require not only work but also job training or volunteering -- cannot be used as a tool to minimize insurance coverage. In a country where 8.8 percent of the population still lacks health insurance, the goal should be to expand coverage, not shrink it.
Keep in mind that most people on Medicaid who can work do so. To go through the numbers: About 43 million adults received Medicaid in 2016. Nearly two-thirds of them worked either full- or part-time. Of the remaining third, the vast majority were ill or disabled, taking care of family, in school, retired or looking for work -- which would qualify them for an exemption under the guidelines the government released Thursday.
Just 3 percent were neither working nor looking for work. So the number of people at risk of losing Medicaid due to work requirements, if states are careful, should be small.
Attaching a work requirement to Medicaid is especially tricky, because it is a program that, in providing health care, supports people's ability to have a job. Many Medicaid beneficiaries have chronic health conditions that don't meet the official government definition of disability but still require medical attention.
The federal government's guidelines point out such pitfalls. They also note that states will be expected to define reasonable exceptions from the rule (for people in addiction treatment; for example), provide work support programs (assistance with transportation and child care, for example); and keep track of how many people get jobs or lose insurance because of work requirements.
The guidelines also promise that state work requirements for Medicaid will improve beneficiaries' health by engaging them in productive activities. Of course, a more direct way to encourage work among the same population would be to increase the federal earned income tax credit.
But if they can help beneficiaries find jobs and expand or preserve access to health insurance, work rules are worth trying. To date 10 states have applied for the waiver that will allow them to impose these requirements; Kentucky, whose governor campaigned on repealing the Affordable Care Act's expansion of Medicaid, is poised to go first.
It remains to be seen whether his colleagues in the 18 states that have resisted the expansion will now be more amenable to expanding Medicaid. But if they are, and they should be, then more Americans could gain access to affordable health insurance.
--Editors: Mary Duenwald, Michael Newman.
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