Why Medicaid "work requirements" are a dangerous lie

They have nothing to do with work. Instead, they're designed to enable a purge

Welcome to a Thursday edition of Progress Report.

First, thank you to everybody who offered kind words about my cousin’s tragic passing over the weekend. I plan on responding, but it’s been a tough week. I’m getting back into things and appreciate your patience.

Today we’re diving deep into the Republican Party’s latest war on working people and the social safety net, and how the media is helping them lie to the American public.

There are some other news items to cover, like the Missouri GOP’s decision to spit in voters’ eyes and put both an abortion ban and repeal of paid leave on the ballot, and I’ll cover those things in an upcoming edition of the newsletter.

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Republicans plan to purge Medicaid, not implement “work requirements”

After weeks of negotiations and in-fighting over how exactly they would slash Medicaid to pay for their enormous tax cuts, Republicans this week settled on what has become colloquially known as “work requirements.”

But the phrase “work requirements” is both deeply misleading — and unfortunately almost universally used by the political media. Whether out of ignorance, laziness, or false balance, the media’s use of the term ignores the actual structure of the proposal and the reams of data that indicate its fallacy. The ongoing acceptance of the conservative frame is a boon to Republicans, whose political fortunes are tied to the misinformed public backlash against critical services.

Most people on Medicaid who can work, do

Conservatives have long claimed that adding preconditions to public benefits for the poorest Americans would encourage them to become self-sufficient.

It’s a subtly — or often overtly — racist argument that is built on several fundamentally faulty pretenses, starting with the idea that recipients are lazy and don’t want to work.

In fact, it’s the exact opposite: Medicaid benefits the poorest Americans, a significant number of whom are elderly and/or disabled, which means that they are simply unable to work. But among those who can work, Medicaid is hardly some free ride.

In 2023, there were 26 million Medicaid recipients ages 19-64 who did not also receive Social Security disability benefits. Of those 26 million beneficiaries, 16.6 million of them — or 64% — worked full- or part-time jobs.

Not working is usually not a choice

Of the remaining 32% of these Medicaid recipients who didn’t work, nearly all of them had extenuating circumstances:

Here’s how that 32% breaks down:

• 33% were engaged in full-time caregiving for parents, children, or other family members

• 11% suffered from chronic illness, mental illness, or disability, though were not officially classified as disabled by the government

• 11% said they were searching for work but were unable to find anything (often due to lower educational attainment or age)

• 8% did not work because they were attending school

• 7% were either unable to find a job or forced into early retirement

• 30% offered other reasons, including lack of transportation, unstable housing, prior convictions, and providing caring for non-relatives

Here’s another way to look at it: the younger, healthier, and more educated the Medicaid recipient, the more likely it is that they were working.

Here’s how those aforementioned 26 million Medicaid recipients broke down by demographic:

Think about it: desk jobs tend to go to people with higher levels of education, which turns chronic health issues into especially steep barriers to employment for people without college degrees.

The “unemployed” Medicaid recipient is hard to employ

Another study of government data from 2023, this one produced by the Milbank Memorial Fund, zeroed in further on those recipients who do not work. Its breakdown of age underscored just how determinative those factors are when it comes to whether or not a Medicaid recipient is an active member of the workforce.

• Nearly 40% of non-working Medicaid beneficiaries ages 18-64 are at least 50 years old

• Another 16% of non-working Medicaid beneficiaries ages 18-64 are under the age of 25, meaning that they’re most likely students

The Milbank study also looked at a more narrow definition of “able-bodied,” which excludes Medicaid recipients who have dependent children under the age of 18 as well as those who report chronic illness but do not get disability benefits.

Surely, that very specific definition would match the population that is overwhelmingly young, healthy, and keyed up to work, right?

Yeah, not so much.

Instead, the study found that the people who would ostensibly be most likely to lose their health insurance under the new GOP policy are desperately poor middle-aged women with little education who live in multi-generational households and are forced to work as unpaid caregivers.

And that’s the good faith, low-impact interpretation of the conservative plan!

The GOP proposal would also require some Medicaid recipients to pay for services, but it’s the “work requirement” rule that’s being positioned as the key to cutting the $715 billion in spending needed to offset the party’s gigantic tax cuts for the wealthy.

But if most people on Medicaid already work or qualify for an age or disability exemption, is it really possible to save three quarters of a trillion dollars by chasing a few million older, sicker, and otherwise highly burdened individuals off their health insurance?

No, of course not. But that’s not actually the plan. Because again, working isn’t the real hurdle here.

Instead, Republicans want to kick upwards of nine million poor Americans off of Medicaid by forcing them through a bureaucratic nightmare that has little to do with employment, work ethic, or income.

“Work requirements” don’t work

During Trump’s first term, when he employed more technocratic ways of immiserating people, his HHS began granting waivers to states that wanted to implement their own “work requirements.”

Only Arkansas was able to get its program off the ground and into legal effect before Covid struck — Joe Biden rescinded the waivers in 2021 — but what transpired in the state clearly indicated the actual intent of the conservative means test.

Arkansas required Medicaid recipients to work at jobs or be able to prove that they were actively looking for jobs for at least 20 hours per week. In just nine months, more than 18,000 people — or a quarter of all people subject to the prerequisite — were thrown off the Medicaid rolls, with little correlation to employment.

In fact, most were officially removed not because they weren’t working, but instead because they did not navigate the thicket of regular paperwork required to keep their benefits every month.

In many cases, they were not even aware of the specifics of the mandate, because again, the average beneficiary at risk of losing benefits is older and deeply poor, and often occupied by onerous caretaking responsibilities and/or their own infirmity. And accordingly, losing their health care did not suddenly inspire people to go out and get good-paying jobs: Arkansas saw no increase in employment connected to the disenrollment.

It’s also worth noting that Arkansas was not an aberration. The program there only ended because a court order paused its authorization, whereas the programs in Michigan and New Hampshire were preempted by court orders. Had judges not intervened in those two states, around 10,000 Medicaid beneficiaries would have lost their health care in New Hampshire and 80,000 poor people would have been shit out of luck in the Upper Midwest.

Then came the national purge.

The Great Abandonment continues

During the pandemic, when the federal government was actively trying to provide people with direct assistance and prevent total economic collapse, state Medicaid officials were forbidden from conducting “redeterminations,” or checking to see who was no longer eligible and removing them from the program. President Biden inexplicably agreed to end that pause on redeterminations in 2023, which opened the door to conservative states to unleash years of pent up fury on their poorest residents.

They called this the Medicaid Unwinding, but that suggests something far more orderly than what actually transpired. It was more like pure chaos and cruelty than anything else. As I documented extensively at the time, many states rushed to remove as many people as possible from the Medicaid rolls, cutting corners, breaking regulations, and ignoring feckless warnings from the Biden administration to maximize the pain.

Medicaid recipients are far less likely to have long-term stable housing, so they tend to more frequently change their addresses. That trend skyrocketed during the pandemic, when low-income Americans were hit disproportionately by mass layoffs and illegal evictions. Many more moved in with family to serve as caregivers. All told, millions of recipients changed their addresses, and because they were not required to at the time, did not inform their state health care agency.

Whereas they were supposed to give Medicaid recipients every opportunity to respond to official inquiries, and were even provided the tools to use internal tax data to determine eligibility without even needing to check in with them, GOP-led states purged people before they even knew that they had to respond.

All told, 25 million people were kicked off of Medicaid, including 5.1 million children. Of those 25 million, 69% of them lost their insurance due to procedural errors, not because they were no longer eligible. Those “errors” largely involved paperwork that did not get done — or even get to them.

The private market could not compensate for this mass exodus, for the same reasons why people were on Medicaid in the first place: they were too poor to afford to buy insurance and too sick or otherwise burdened to get a job that would provide it. All told, 12.5 million people who lost Medicaid could not get private insurance, swelling the ranks of the uninsured.

Republicans can talk about personal responsibility and rooting out fraud and waste, but in reality, this kind of cruel and capricious purge is what Republicans want to do to Medicaid and the US health care system. They’re itching to give states carte blanche to kick the poorest Americans off of a meager public benefit, irregardless of whether they work.

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