By Larisa Antonisse and Rachel Garfield
Kaiser Family Foundation, August 7, 2018
A central question in the current debate over work requirements in Medicaid is whether such policies promote health and are therefore within the goals of the Medicaid program. Work requirements in welfare programs in the past have had different goals of strengthening self-esteem and providing a ladder to economic progress, versus improving health. This brief examines literature on the relationship between work and health and analyzes the implications of this research in the context of Medicaid work requirements. We review literature cited in policy documents, as well as additional studies identified through a search of academic papers and policy evaluation reports, focusing primarily on systematic reviews and meta-analyses. Key findings include the following:
Being in poor health is associated with increased risk of job loss, while access to affordable health insurance has a positive effect on people’s ability to obtain and maintain employment.
There is limited evidence on the effect of employment on health, with some studies showing a positive effect of work on health yet others showing no relationship or isolated effects. There is strong evidence of an association between unemployment and poorer health outcomes, but authors caution against using these findings to infer that the opposite relationship (work causing improved health) exists. While unemployment is almost universally a negative experience and thus linked to poor outcomes, especially poor mental health outcomes, employment may be positive or negative, depending on the nature of the job (e.g., stability, stress, hours, pay, etc.). Further, most studies note major limitations in our ability to draw broad conclusions on health and work, including:
- Job availability and quality are important modifiers in how work affects health; transition from unemployment to poor quality or unstable employment options can be detrimental to health.
- Selection bias in the research (e.g., healthy people being more likely to work) and other methodological limitations restrict the ability to determine a causal work-health relationship.
Studies note several caveats to and implications of the research on work and health that are particularly relevant to work requirements in Medicaid. For example:
- The work-health relationship may differ for the Medicaid population compared to the broader populations studied in the literature, as Medicaid enrollees report worse health than the general population and face significant challenges related to social determinants of health.
- Limited job availability or poor job quality may moderate or reverse any positive effects of work.
- Work or volunteering to fulfill a requirement may produce different health effects than work or volunteer activities studied in existing literature.
- Loss of Medicaid coverage under work requirements could negatively impact health care access and outcomes, as well as exacerbate health disparities.
NBER Working Paper No. 24899: The Effect of Disenrollment from Medicaid on Employment, Insurance Coverage, Health and Health Care Utilization
By Thomas DeLeire
National Bureau of Economic Research, August 2018
This study examines the effect of a Medicaid disenrollment on employment, sources of health insurance coverage, health, and health care utilization of childless adults using longitudinal data from the 2004 Panel of the Survey of Income and Program Participation. From July through September 2005, TennCare, the Tennessee Medicaid program, disenrolled approximately 170,000 adults following a change in eligibility rules. Following this eligibility change, the fraction of adults in Tennessee covered by Medicaid fell by over 5 percentage points while uninsured rates increased by almost 5 percentage points relative to adults in other Southern states. There is no evidence of an increase in employment rates in Tennessee following the disenrollment. Self-reported health and access to medical care worsened as hospitalization rates, doctor visits, and dentist visits all declined while the use of free or public clinics increased. The Tennessee experience suggests that undoing the expansion of Medicaid eligibility to adults that occurred under the Affordable Care Act likely would reduce health insurance coverage, reduce health care access, and worsen health but would not lead to increases in employment.
New in GOP logic: Antipoverty programs worked so well, we must get rid of them
By Sasha Abramsky
Los Angeles Times, August 10, 2018
For many decades now the GOP has sought to undo the New Deal and the Great Society. But a report released last month from the White House’s Council of Economic Advisors, lost in a sea of grabbier news items, applies a new logic to the goal of shredding the safety net.
According to “Expanding work requirements in non-cash welfare programs,” comprehensive antipoverty programs are no longer necessary because 50 years of antipoverty programs — yes, those same interventions long hated, and their effectiveness belittled, by the GOP — have succeeded so spectacularly that poverty is largely a thing of the past.
The report claims that the War on Poverty led to “the success of the United States in reducing material hardship,” but “that it also came at the cost of discouraging self-sufficiency.” It proceeds to lay out a case for limiting access to benefits and setting in place work requirements in exchange for basic nutritional and medical benefits.
This is beyond disingenuous. Yes, in the years after 1964, when President Lyndon Johnson launched the War on Poverty, the percentage of poor Americans did significantly decline; by some measures it was cut in half from about 22% of the population down to about 11%. But over the last 40 years it has rebounded with a vengeance.
Expanding Work Requirements in Non-Cash Welfare Programs
The Council of Economic Advisers, July 2018
Aiming to transition more non-disabled working-age Americans into the workforce, President Trump signed an executive order in April 2018 instructing agencies to reform their welfare programs by encouraging work and reducing dependence, in part by strengthening and expanding work requirements.
By Don McCanne, M.D.
Heath care financing programs should be designed to enable individuals to have affordable access to the health care that they need. Medicaid is specifically designed to assist low-income individuals in obtaining that care who otherwise do not have the resources to pay for it. How does having a work requirement to qualify for Medicaid help with this goal of improving access? Well, it doesn’t.
The Kaiser Foundation report shows that a Medicaid work requirement can have many deleterious effects. In fact, penalizing unemployed individuals by disqualifying them from Medicaid coverage can “negatively impact health care access and outcomes, as well as exacerbate health disparities.” Isn’t that the opposite of what we should be doing? So why should we have a policy in place that does that?
The NBER paper shows that disenrolling individuals from the Tennessee Medicaid program reduced health care coverage, reduced health care access, worsened health outcomes, but did not lead to increases in employment. There is a disconnect between Trump’s executive order to expand work requirements to qualify for non-cash welfare programs and achieving the goals of those programs, including health care under Medicaid.
What is this, tying health care to work? A well designed health care financing program should ensure affordable access to health care for everyone, regardless of any other considerations. A work program should be designed to ensure that all capable individuals can get the work that is most appropriate for them. But one program should not be dependent on the other.
Again, health care for low-income individuals should not be dependent on their work status. Everyone who needs health care should have it. Instead of a separate program for those with lower incomes – Medicaid – we should have one program that is equitable, affordable, efficient, and accessible for everyone – a well designed, single payer, improved Medicare for all. We can also go to work on ensuring that decent jobs with decent wages are available to individuals based on their capabilities, but that should be a separate project.
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