On April 26, the House passed Speaker Kevin McCarthy’s debt ceiling bill, the “Limit, Save, and Grow Act.” If enacted, the bill would create new work reporting requirements, stripping Medicaid coverage from adults unable to document eighty hours of work or community service per month. This commentary outlines how work reporting requirements are unnecessary, harmful, and ultimately counter to the goals of the Medicaid program. First, it describes the reality of Medicaid beneficiaries’ working status. It then discusses how work reporting requirements would jeopardize coverage even for beneficiaries who meet the requirements. Finally, it highlights the fact that work reporting requirements are rooted in racist perceptions of low-income people, and are deeply ableist in nature, to boot.
Most Medicaid beneficiaries already work.
Medicaid is a joint federal–state public insurance program that provides health coverage to low-income people, many of whom are disabled and qualify through their disability status. Proponents of work reporting requirements for Medicaid argue that they promote “personal responsibility” among Medicaid beneficiaries. This approach is both insulting to Medicaid beneficiaries and represents a solution in search of a problem. According to a recent analysis of Census Bureau data by the Kaiser Family Foundation, more than 60 percent of non-elderly Medicaid beneficiaries who did not qualify for the program through supplemental security income enrollment worked at least part-time. The same analysis found that of the remaining enrollees, the overwhelming majority of those would likely qualify for one of the exemptions in the House GOP bill:
- 13 percent were not working due to caregiving responsibilities,
- 11 percent were not working due to illness or disability, and
- 6 percent were not working due to school attendance.
The remaining 9 percent of Medicaid enrollees who were not working at the time is a broad group, including both retirees and people who were unable to find work. Figure 1 shows the makeup of work status among Medicaid beneficiaries.
This approach is both insulting to Medicaid beneficiaries and represents a solution in search of a problem.
Work reporting requirements disenroll eligible families.
Because most Medicaid beneficiaries already work or would be exempt, it would be reasonable to assume that these requirements would have little impact on enrollment. The reality, however, is that these requirements would create an additional, significant administrative burden for Medicaid enrollees to comply with to maintain their coverage. This is why this commentary uses the term work reporting requirements—these types of policies require that beneficiaries report their work status, and premise eligibility for basic human needs programs on whether someone can successfully navigate an extra layer of red tape. As discussed below, they also limit enrollees’ ability to find work: access to affordable, high-quality health care is essential to find work.
These types of policies require that beneficiaries report their work status, and premise eligibility for basic human needs programs on whether someone can successfully navigate an extra layer of red tape.
These types of paperwork requirements significantly reduce beneficiaries’ ability to maintain their coverage. For example, when Arkansas implemented Medicaid work reporting requirements in 2018, more than 18,000 people were kicked out of the program within a year of implementation. Research by the Kaiser Family Foundation concluded that much of this disenrollment was not because enrollees were not working or exempt, but because they were either unaware of the requirements or unable to successfully report their work or exemption. As Medicaid enrollees are disproportionately likely to live in a house without internet or with limited computer access, this is unsurprising. The same research by KFF found that the requirement did not create an additional incentive to work, but simply added stress to their lives, a finding echoed in research by the Center on Budget and Policy Priorities.
While the House bill encourages states to “prioritize the utilization of existing databases or other verification measures,” the reality is that enrollees would still likely be on the hook for demonstrating compliance in many states. A similar requirement exists for Medicaid eligibility redeterminations, but most states complete fewer than half of their renewal determinations through existing data. Figure 2 shows the proportion of Medicaid renewals that states report completing through administrative data.
In addition, states currently face a significant workforce challenge in part due to the unwinding of the continuous coverage requirement for Medicaid enrollees. States are redetermining Medicaid enrollees’ eligibility for the first time in several years, and this process alone will require serious effort by state Medicaid agencies to achieve with minimal loss of coverage. Imposing an additional requirement on states when their workforce is already spread thin will only increase the likelihood of inappropriate disenrollment while creating additional unaccounted expenses.
Imposing an additional requirement on states when their workforce is already spread thin will only increase the likelihood of inappropriate disenrollment while creating additional unaccounted expenses.
Work reporting requirements are racist and ableist in nature.
In addition to the fact that work reporting requirements are counterproductive to the goal of the Medicaid program—providing comprehensive health coverage to low-income people—these requirements are both racist and ableist in nature. Part of this is due to the fact that, because of structural and historical barriers, people of color and disabled people are more likely to work lower-paying jobs and jobs which do not provide health coverage as a benefit, making Medicaid cuts and added administrative burden in the Medicaid program more likely to impact them. Beyond this, however, work reporting requirements are often aimed at the idea that these groups need incentives to work and are implemented in ways that disproportionately impact them even among Medicaid enrollees.
First, work reporting requirements are rooted in the racist ideology that Black women and other low-income people of color are lazy and do not value work. This idea is decades old and has fueled work requirements in many public assistance programs. For example, during the passage of the law establishing the Temporary Assistance for Needy Families (TANF) program, much of the discussion focused on Black mothers, described as needing a “stick” to encourage them to work. The idea is present in this present bill: Speaker McCarthy described the goal of Medicaid and other public assistance programs as “a hand up, not a handout.”
In addition to their racist origins, work reporting requirement implementation methods have been proposed in racist ways in the past. When Michigan proposed its work reporting requirements in 2018, for example, the bill would have exempted counties with unemployment rates above 8.5 percent. While this seems like a sensible exemption to address areas of the state with limited employment opportunities, it functionally carved out counties with higher Black populations, even if those counties still had substantial unemployment rates. Genesee and Wayne Counties, home of Flint and Detroit, respectively, both had employment rates of more than 5 percent, but would not have been exempted from the work reporting requirement.
Although their proponents often claim disabled people will be protected from loss of coverage due to exemptions, work reporting requirements will, in fact, disproportionately harm disabled people who rely on Medicaid for health care coverage. First, many disabled people do work or are trying to find work, and may not fit one of the exemptions. Most people today define disability broadly: the Americans with Disabilities Act definition captures the more than 61 million adults with disabilities in the United States. However, those receiving Medicaid may fall under the Social Security Administration’s strict disability definition and criteria and be captured under the work reporting requirement exemption or they may not, leaving them at risk for losing coverage despite their disability.
For those that do not fit the Supplemental Security Income/Social Security Disability Insurance criteria, they are still disabled by law, but could very well lose benefits. For example, when Arkansas implemented its work reporting requirements, it heavily relied on exemptions to protect disabled enrollees from losing coverage. However, in spite of this, more than half of the enrollees who would not qualify for other exemptions had one or more serious health limitations or disabilities. Losing coverage due to work reporting requirements would mean worsening health for disabled enrollees. Ironically, this would make it even less likely that those receiving Medicaid benefits are able to work.
Work reporting requirements reinforce a more broad, problematic narrative—that individuals who benefit from public programs like Medicaid are “fakers” or “takers” of government services and need to be brought to heel.
Further, work reporting requirements reinforce a more broad, problematic narrative—that individuals who benefit from public programs like Medicaid are “fakers” or “takers” of government services and need to be brought to heel. These types of policies are further premised on the notion that a human being’s worth comes from their work status, a toxic worldview that we as a society would do well to resoundingly reject.
Congress should reject work reporting requirements.
As Congress determines the legislative vehicle for raising the debt ceiling, it should reject calls to include work reporting requirements in the eventual bill. These requirements are directly counter to the purpose of the Medicaid program, and imposing these requirements on beneficiaries will only result in low-income individuals and families—including significant numbers of people with disabilities—losing critically needed health coverage and services. Achieving universal coverage is essential to achieving health equity, and these requirements would be a dangerous step backward in achieving that goal.