Noah Zatz is a professor at UCLA School of Law.
Republicans revile such bureaucratic rigidity when it inconveniences businesses or the wealthy. Yet they embrace it when it hurts the most vulnerable. We’ve seen this Republican red tape with onerous voter-ID requirements. The American Health Care Act passed by the House to repeal Obamacare is the latest example.
Now pending in the Senate, the House bill would authorize states to impose work requirements on low-income adults who access health care through Medicaid. Adding these requirements — also present in the president's budget — was one of several sweeteners for the GOP's reluctant right wing. Largely a legacy of 1990s-style welfare reform, stringent work requirements currently apply to federally funded safety nets for cash, food and housing, but not health care. Two decades of experience show why these rules are an especially poor fit for Medicaid.
The health-care context magnifies work requirements’ failings. They function mainly to pump out “sanctions,” denials of benefits for running afoul of bureaucratic requirements. The House bill would subject Medicaid enrollees to the same gantlet of busywork that cash recipients already must run. To enforce work requirements, caseworkers assign a stream of employability assessments, “work activities” and reporting obligations. Each mandatory task creates an opportunity to trip someone up and cut them off.
These hassles offer little benefit. Their advocates’ argument — that people need to fear dying of untreated illness to motivate them to work — is cruel and absurd. Whether or not you have health insurance, you still need to pay for food, shelter and clothing. The threat of losing health care hardly increases the financial pressure to work.
Research consistently shows that most sanctions stem from a missed appointment or an incomplete form. Actually refusing a job or interview rarely occurs. Hassling you for seeking help not only denies benefits outright but also discourages people from seeking support in the first place.
Predictably, the most vulnerable bear the heaviest burden. The same challenges that lead people to need assistance in the first place also increase the risk of a misstep in navigating the work bureaucracy. Studies of welfare sanctions repeatedly find that health problems, caregiving obligations and unstable housing or transportation are more widespread among those sanctioned.
Medicaid enrollees are especially endangered by this kind of red tape: A Kaiser Family Foundation report found that, among those not already working, about one-third cite poor health as the reason. Just more than one-fourth cite family responsibilities, and one-fifth cite school attendance. In principle, missing an appointment can be excused for a good reason, such as a child-care or health crisis, but the government bureaucracy can be unforgiving and judgmental. And other research has shown that these judgments are distorted by racist stereotypes about work effort, leading to disproportionate sanctioning against African Americans.
Worse, several financing features of the House bill perversely encourage the use of work requirements to drive people off Medicaid. In a war of attrition against Obamacare’s Medicaid expansion, the federal government will start reducing support for new enrollees, thereby shifting costs to the states and encouraging cutbacks. Those already enrolled are grandfathered in — unless they lose coverage for longer than one month. Work sanctions are the perfect tool to generate those coverage breaks that strip away grandfathered status. This explains why the bill includes extra funding to help states create work-requirement bureaucracies. The federal money spent on creating red tape will be offset by savings from denying coverage. These breaks in coverage can also trigger the bill’s provisions allowing discrimination against people with preexisting conditions.
The bill's "per capita cap" creates similar incentives. This provision limits federal reimbursement to a state if its average enrollee's care gets more expensive due to rising prices or expanding needs. Above the caps, states bear all the costs. This creates financial pressure to cut off people with more serious (and expensive) problems, leaving healthier people enrolled and driving down average costs. Work sanctions will do this by inherently targeting sicker adults who find it harder to work and navigate the bureaucracy precisely because of their illnesses.
Finally, the House bill’s Medicaid block-grant option also invites using work requirements as a sanction machine. Participating states receive the same amount of federal money regardless of how many people they enroll. Cutting someone off Medicaid allows the state to keep the money and use it for something else.
Anyone serious about streamlining the health-care system should oppose grafting on this additional bureaucracy. But if the GOP’s real goal is to fund tax cuts for the wealthy, cut coverage for the most vulnerable and evade responsibility by blaming the victim, then work requirements are shamefully perfect.
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