“I’m willing to swallow the toad and take my lumps.”
— Del. Bobby Orrock, 2004
Delegate Orrock’s words are from another time, when a group of 17 House Republicans bucked their leadership, their local party units and the anti-tax wing of their base to endorse a sales tax increase and end the ongoing budget showdown with the GOP-controlled Senate.
But his colorful statement captures the plight of House Republicans today, who have embraced Medicaid expansion but with conditions and requirements in tow.
One of those conditions is a work requirement designed so that “every able-bodied, working-age adult enrolled in the Medicaid program” will, through employment, education or job training, “increase their health and well-being through community engagement leading to self-sufficiency.”
Jonathan Ingraham, vice president of research for the Foundation for Government Accountability, said work requirements “are a commonsense tool to move able-bodied adults from welfare to work.”
But, Ingraham said, work requirements “are not an excuse to expand welfare to a new class of able-bodied adults under Obamacare” and divert scare state resources away from other spending priorities such as education, public safety and help “for the truly needy.”
Strip away the boilerplate and Medicaid expansion in this view is little more than a return to the “welfare queens” of yore. Work requirements will, at minimum, get them off the couch and into the workforce.
But defenders of expansion say it’s not welfare. Rather, it’s insurance, and efforts to alter the program are an assault on the underlying Medicaid law. They are litigating Kentucky’s work requirements and other expansion conditions in federal court.
Virginia’s proposed work requirements are not nearly as onerous as Kentucky’s, which is one reason Senate Republicans are attacking the proposal as window dressing.
Republican senators opposed to expansion point to a Kaiser Family Foundation report that shows most of those on Medicaid already work:
Six in ten Medicaid adults are already working Among those who are not working, most report illness or disability, caregiving responsibilities, or going to school as reasons for not working. Many of these reasons would likely qualify as exemptions from work requirement policies. This would leave 7% of the population to whom work requirement policies could be directed, including those who report they are not working because they are looking for work and unable to find a job.
Those are national numbers. In Virginia, a Department of Planning and Budget fiscal impact statement of House Bill 338 establishing work requirements for current Medicaid recipients would affect “approximately 18 percent of the fully enrolled expansion population (approximately 50,000 individuals).”
Those who can’t meet the requirements would be “dis-enrolled from coverage.”
A larger, and more important, question about linking work requirements to Medicaid eligibility leads to improved health. According to the Kaiser Foundation report, it’s not clear they do:
…some research show[s] increased income or employment is associated with improved health outcomes and mortality, it is difficult to determine the direction of causation—whether income and work lead to better health, or whether better health facilitates income and work. In addition, research has found some deleterious health effects of work, particularly for people in shift work positions or those with high job insecurity, and evaluations of existing work requirements in other programs find weak evidence for an effect on health and well-being. There is some evidence of positive effects in programs targeted to people eligible for Medicaid on the basis of a disability, but work is voluntary under those programs, and Medicaid provides a full range of supportive services to enable individuals to continue coverage as income increases.
Sketchy evidence aside, work requirements sound tough and conservative: Those would-be welfare queens won’t be able to game this system!
It helped some House Republicans to swallow the toad without retching.
All that’s left is taking their lumps. Senate Republicans will oblige.
But keep an eye on the Republicans representing suburban districts. Republicans got walloped in those areas in 2017, and their prospects may be getting only worse.
If so, suburban Republican senators might have no choice but to put toad on the menu.