Medicaid expansion’s unsteady march is a story of encouraging but incomplete victories. The Democratic surge in Virginia’s statewide elections last year allowed expansion to finally clear longstanding political hurdles, but legislators still had to include a few compromise measures in order to secure a handful of Republican votes. Among those measures were work requirements for Medicaid recipients, which are now poised to emerge in many other states—and not for the greater good of passing expansion, but simply because the Trump Administration plans to allow states to engage in unprecedented and harmful new forms of Medicaid tinkering.
This story begins at the familiar intersection of federalism’s messiness and the GOP’s governing priorities. Earlier this year, the Trump Administration informed state Medicaid directors that it would begin supporting their efforts to “make participation in work or other community engagement a requirement for continued Medicaid eligibility.” At the time of the announcement, a number of states had already requested permission to impose work requirements; waivers have since been approved in three states, with many others in line to follow.
State flexibility, on its own, is nothing new: Medicaid already permits state-level modifications to the standard federal rules under what are known as Section 1115 waivers. But as Philip Rocco points out in a Scholars Strategy Network brief, such waivers only allow state-level modifications that advance Medicaid’s legally defined goal, which is to furnish medical assistance to people who can’t afford it.
It’s not at all clear that forcing Medicaid recipients to work meets that requirement. In order to get around this legal problem, Trump’s Administration has had to argue that work requirements will, somehow, help low-income people access medical assistance. This is a problem, since, as Rocco writes, “research actually suggests that imposing work requirements is unlikely to improve health outcomes.” They “create costly and confusing bureaucracy for millions of low-income Americans who will have to periodically recertify their work status with multiple state agencies,” with the predictable result of coverage losses for people who make some mistake or fail (even for understandable reasons) to fully comply with these bureaucratic burdens. The Administration’s response to such criticisms rests on insisting that employment improves health—which, according to researchers, gets things backward: It’s not that working makes you healthier; it’s that healthy people are more able to find and keep work. A lawsuit challenging the new waivers was filed in January.
If you can get through the Administration’s lazy defenses of the work requirements (Trump’s head of the Centers for Medicare and Medicaid Services insists that they’re about “helping people achieve the American Dream”), the policy is a revealing window into the Republican mind. As Noah Zatz pointed out last year in The Washington Post about similar plans in the failed American Health Care Act, the chief effect of work requirements is mainly to subject Medicaid recipients to a “gantlet of busywork,” with the ultimate result of stripping health care away from the needy. Under similar policies for welfare recipients, Zatz noted, most sanctions have resulted from such grave offenses as “a missed appointment or an incomplete form”—which, of course, are more common among people with unpredictable or overwhelming demands related to childcare, reliable transportation, shifting work schedules, health, and so on.
The erection of such pointless hurdles for low-income Americans trying to access health care is a compelling example of the harm that can be caused by red tape. Republicans’ pursuit of those hurdles, then, makes their parallel celebrations of other regulatory rollbacks positively surreal. Consider this Heritage Foundation commentary from December, which reassured readers that Trump is acting “to decrease the total burden of regulation on Americans.” By “Americans,” you might think the author is referring to, well, American people. But the article’s parade of victories are mostly handouts to industry, like the EPA’s steps against the Obama Administration’s Clean Power Plan and the FCC’s reversals on net neutrality and broadcast media mergers. Undoubtedly there are many GOP-allied corporations that like these ideas just fine, but it’s harder to imagine average Americans suffering under the bureaucratic tyranny of an inhabitable planet, a usable Internet, and a diverse news media not dominated by conservative propagandists. The absence of these priorities, and the looming onset of Medicaid work requirements, make for a strange pairing with Heritage’s sunny announcement that the liberating work of regulatory rollback has only just begun: “there are a number of initiatives well underway aimed at repealing significant and costly rules.” As the waivers show, however, there are other initiatives under way aimed at creating significant and costly rules. That they have somehow escaped the concern of people who claim to care about crushing regulatory burdens is a pretty good indicator of where their priorities lie.