IN CONTRAST with those of other advanced industrial democracies, especially in Europe, the U.S. system of social insurance and income support distributes benefits based not only on membership in society, but also on work effort, past and present. In the realm of health insurance, this means that instead of adopting universal coverage as a national legal standard, then devising a unitary system to meet that goal, the United States cobbled together programs whose organizing principle, such as it is, is work. A plurality of adults get tax-subsidized insurance through their employers; most retirees get Medicare, paid for out of deductions from their past paychecks. Many others — poor children, people with disabilities — obtain insurance from programs whose premise is that the recipients are neither expected nor able to work, which is itself a work-related criterion.
This makes no actuarial sense, because the need for health care and work are not necessarily connected. It created the impediment to worker mobility known as “job lock.” And it created a large and chronic coverage gap for working-age, non-disabled adults who lacked jobs, or whose employers did not provide insurance but paid their employees too little for them to buy it on their own.
Obamacare tried to fill that gap — and break the link between work and insurance — by opening up a subsidized individual market and by admitting millions of working-age adults to Medicaid. This was progress, both ideologically and substantively. And now the Trump administration proposes to undermine it by allowing states to require non-disabled adults to work for Medicaid benefits heretofore provided based on only income.
This is a solution in search of a problem. The majority of the target population already work (60 percent) or live with a worker (79 percent) , according to the Kaiser Family Foundation. So even if the official rationale for the new policy — the Department of Health and Human Services says work improves health — is valid, it’s superfluous in most cases. Of those who aren’t working, many have care-giving responsibilities that either they would have to abandon or states would have to accept as the equivalent of work outside the home, after a lot of complex and expensive administrative hassle.
Eight states have petitions pending for the relevant legal waiver that would allow them to impose work requirements. Of these, five expanded Medicaid through Obamacare, so the necessary effect would be to tighten eligibility for that population, ending coverage for at least some poor people who have it now. (A waiver for Kentucky, also an expansion state, has just been approved.) Of the other states that did not expand Medicaid, the new policy would, in some cases, add to administrative burdens without affecting work incentives for anyone except a relative handful of non-disabled adults.
And, of course, people who can’t meet a work requirement will not cease seeking medical care; they will get it as they used to before Medicaid, by showing up at emergency rooms, where they must be treated, often at higher expense than would have been the case if they had insurance.