The Washington PostDemocracy Dies in Darkness

Republicans threaten to deny poor people medical care if they aren’t working

Rep. Paul Ryan (R-Wis.) and Sen. Mitch McConnell (R-Ky.) watch President Trump deliver his inaugural address on Jan. 20. (Photo by Chip Somodevilla/Getty Images)

Republicans moved to require able-bodied, poor Americans to work in order to receive publicly funded health insurance through Medicaid on Thursday, advancing a long-held goal of conservative reformers.

These work requirements address a common concern of policymakers around public-assistance programs: that the poor will not look for work, because if they earned more, they might no longer be poor enough to qualify for help. Additionally, for Republicans and many Democrats, work requirements are a matter of fairness.

“When Medicaid was created, it wasn’t intended to become an entitlement for able-bodied adults,” said Rep. Gary Palmer (R-Ala.), introducing the proposal to include Medicaid work requirements in Republicans' health care bill.

Republicans on the House budget committee voted to include the proposal, a one-sentence motion that leaves the details of the plan for later in the legislative process. But like Republicans' health care bill itself, it has many hurdles left to clear to become law.

Many forms of public assistance, including food stamps, require recipients to work, look for work, volunteer or participate in vocational training. The work requirements vary from one program to the next and have varying requirements vary by the program and traits of the recipients, such as their ages and whether they have children.

Yet when it comes to health insurance, such requirements would be nearly impossible to enforce, conservative and independent experts on the Medicaid program said Friday.

"It's not entirely clear that this requirement makes a lot of sense," said Dr. Benjamin Sommers, a public-health expert at Harvard University.

The majority of adults receiving Medicaid already are working. Currently, about 78 percent of adults enrolled in Medicaid who are not elderly live in households with at least one person working, according to an analysis by the nonpartisan Kaiser Family Foundation. Those who are not working might have good reasons for doing so, said Diane Rowland, an executive vice president at the foundation.

Can President Trump keep his many promises about health care? (Video: Peter Stevenson/The Washington Post, Photo: Bill O'Leary/The Washington Post)

Experts also questioned whether officials were really prepared to deny medical care to people who were seriously ill because they had not been working.

The proposal "misses the point," said Robert Rector, an expert on welfare at the conservative Heritage Foundation, who dismissed the plan as "largely a matter of press release, not policy substance."

Rector was skeptical that governors and other state officials would enforce the requirements strictly, if at all. He pointed out that if a person wanted to avoid the requirement, she could simply not enroll in Medicaid unless she became ill, at which point she could go to a hospital or a clinic and enroll then.

"It’s very difficult to deny an individual medical services when they’re sick," he said. "It seems reasonable to say, 'Well, if society is going to care for you, or assist you, you should do something back in return.' The problem is it’s very difficult to do that with regard to medical care."

The analysis from the Kaiser Family Foundation, based on federal surveys, suggests that about 18 percent of adult Medicaid beneficiaries who are not working are in school. Another 28 percent report that they are taking care of members of their family, and 35 percent say that they are sick or disabled.

"People who can work, try to work," the foundation's Rowland said. "They’re working in gas stations and restaurants in places -- unless they live in San Francisco -- where they don’t get health benefits."

The Republican recommendation is limited to able-bodied adults without children or other dependents. Rowland pointed out, though, that states would presumably have the difficult task of determining who would be considered "able-bodied" and subject to the requirements, and who is too sick to work.

Nor is there evidence that Medicaid discourages beneficiaries from getting jobs.

Researchers had an opportunity to test this theory in Oregon, when the state expanded Medicaid to a larger group of residents using a lottery. The group that lost out in the lottery neither worked more nor earned more, the economists who studied the program found.

Other research has come to similar conclusions. A review published in 2012 concluded that Medicaid had "essentially a zero effect" on beneficiaries' decisions about work. That could be because people who qualify for the program are poor enough that they need to work if they can, whether or not they have health insurance.

It is certainly possible that some recipients could be pushed to work, and that they might find private health insurance through their employer as a result.

Even so, Rowland argued that the program was unlikely to save much money from shifting those beneficiaries off the rolls. Those who are healthy enough to work likely cost Medicaid little, she said, while the program spends the bulk of its resources caring for people who will not be able to enter the labor force.

"You probably are not going to do very much to change the cost of the program," Rowland said. "It’s not healthy people who are on Medicaid who cost money."

Michael Strain, an economist at the conservative American Enterprise Institute, agreed that the rule would be "largely symbolic."

He called idea of requiring work in general "reasonable and sound," but added: "If it were a firm requirement, and that meant that somebody who got hit by a bus showed up at a hospital and they weren’t treated, that seems like bad policy to me."

President Trump's views on the question are unknown, but in the past, he has made expansive and inclusive promises about coverage for the poor.

"We’re going to have insurance for everybody," Trump told The Washington Post in January. "There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us."