By Anna Stelter, LMSW, MPH
Last month, Arkansas joined Indiana and Kentucky as the third state to receive approval from the federal Centers for Medicare and Medicaid Services (CMS) to require enrollees in its Medicaid program to work. Beginning in April, non-disabled Arkansas adults under age 50 who are eligible for Medicaid will have to prove they are employed, in school, receiving job skills training, or performing community service at least 20 hours per week to maintain their health insurance coverage. CMS Administrator Seema Verma, explaining her agency’s support of work requirements, remarked “meaningful work is essential to beneficiaries’ economic self-sufficiency, self-esteem, well-being, and health.”
Requiring “able-bodied” Medicaid enrollees to work has emerged as a politically appealing option for states wanting to tailor who can enroll in the program and what benefits they receive. Nineteen other states, most with Republican-led governors and legislatures, have asked CMS to allow them to administer a work requirement. However, Texas is one of a handful of such states that has not yet signaled an intent to require its Medicaid enrollees to work, and doesn’t seem likely to do so.
Because Texas’ recent approach to Medicaid policy has been in line with several states now forging ahead with work requirements, the state's decision not to join the pack might seem curious at first. Yet it’s precisely because of Texas’ restrictive track record on Medicaid that it’s not in position to pursue a Medicaid work requirement. While Medicaid expansion states like Arkansas and Kentucky have a large share of working-age adult enrollees, Texas’ Medicaid program contains barely any enrollees to whom a work requirement could reasonably apply.
Last month, Arkansas joined Indiana and Kentucky as the third state to receive approval from the federal Centers for Medicare and Medicaid Services (CMS) to require enrollees in its Medicaid program to work. Beginning in April, non-disabled Arkansas adults under age 50 who are eligible for Medicaid will have to prove they are employed, in school, receiving job skills training, or performing community service at least 20 hours per week to maintain their health insurance coverage. CMS Administrator Seema Verma, explaining her agency’s support of work requirements, remarked “meaningful work is essential to beneficiaries’ economic self-sufficiency, self-esteem, well-being, and health.”
Requiring “able-bodied” Medicaid enrollees to work has emerged as a politically appealing option for states wanting to tailor who can enroll in the program and what benefits they receive. Nineteen other states, most with Republican-led governors and legislatures, have asked CMS to allow them to administer a work requirement. However, Texas is one of a handful of such states that has not yet signaled an intent to require its Medicaid enrollees to work, and doesn’t seem likely to do so.
Because Texas’ recent approach to Medicaid policy has been in line with several states now forging ahead with work requirements, the state's decision not to join the pack might seem curious at first. Yet it’s precisely because of Texas’ restrictive track record on Medicaid that it’s not in position to pursue a Medicaid work requirement. While Medicaid expansion states like Arkansas and Kentucky have a large share of working-age adult enrollees, Texas’ Medicaid program contains barely any enrollees to whom a work requirement could reasonably apply.
Status of Medicaid Expansion and Work Requirement Waivers, April 2018
Source: The Commonwealth Fund. Status of Medicaid Expansion and Work Requirement Waivers.
Who are Texas' Medicaid Enrollees?
Of the 4.5 million Texans enrolled in Medicaid, approximately 95% are children, people with disabilities, pregnant women, and seniors, all of whom would be exempt from a work requirement, per CMS guidance. The 5% remaining are either low-income parents, young adults under age 26 who have recently exited foster care, mothers in domestic violence shelters, and other small segments of especially vulnerable enrollees. Texas did not expand Medicaid under the Affordable Care Act, and most low-income working-age adults are not eligible to enroll.
Proponents of Medicaid work requirements have frequently suggested Medicaid should not be available to those who would rather rely on coverage from the government than work to earn coverage themselves. However, research hardly supports the suggestion people with Medicaid are unwilling to work. Almost all working-age adult Medicaid enrollees are already working (usually in jobs that do not offer health insurance), seeking work, attending school, or taking care of family members. Most of those who are out of work reported facing severe health-related barriers to work, such as chronic mental or physical illness. It is not clear which Texans a Medicaid work requirement would incentivize into work who aren’t legally exempt, currently employed, or have compelling reasons for not working.
Work Requirements could do More Harm than Good
Conditioning health coverage on work activities risks directly harming the health of out-of-work enrollees and their family members instead of promoting economic self-sufficiency. Under a work requirement, people who are temporarily unable to work for health reasons would lose their access to treatments, prescription drugs, or assistive devices that could facilitate their return to the workforce. People who provide full-time care for very young, ill, or disabled family members would be compelled to balance a job alongside the demands of unpredictable, round-the-clock caretaking, an impossible scenario for many families or employers to accommodate. And at a time when Texas is trying to reverse a statewide trend of rising maternal mortality rates, low-income postpartum women who could not work after delivery would lose access to potentially lifesaving care.
Work Requirements are Complex and Costly
If the mismatch between the target population for a work requirement and Texas’ actual enrollee population is not enough to dissuade state leadership, perhaps the complexity and the price tag is. A work requirement would saddle the state with a costly administrative burden (likely at least several million dollars annually) to create, operate, maintain, and staff systems to verify employment for thousands of enrollees. State leaders would also have to invest time and effort thoughtfully designing how the work requirement will be enforced: What activities qualify as “work”? What do enrollees have to do to prove they are working? How often must someone show proof?
A viable work requirement would also have to be flexible enough to accommodate circumstances characteristic of low-wage work and poverty. For example, many low-income people move frequently, work cash-only jobs, lack control over the number of hours they work per week, have criminal histories, or lack a high school diploma, all of which could impact a person’s ability to seek, keep, and prove their employment.
The bottom line: A work requirement is not well suited to Texas' current Medicaid enrollee population, and would present a serious administrative and budgetary challenge to the state.
Who are Texas' Medicaid Enrollees?
Of the 4.5 million Texans enrolled in Medicaid, approximately 95% are children, people with disabilities, pregnant women, and seniors, all of whom would be exempt from a work requirement, per CMS guidance. The 5% remaining are either low-income parents, young adults under age 26 who have recently exited foster care, mothers in domestic violence shelters, and other small segments of especially vulnerable enrollees. Texas did not expand Medicaid under the Affordable Care Act, and most low-income working-age adults are not eligible to enroll.
Proponents of Medicaid work requirements have frequently suggested Medicaid should not be available to those who would rather rely on coverage from the government than work to earn coverage themselves. However, research hardly supports the suggestion people with Medicaid are unwilling to work. Almost all working-age adult Medicaid enrollees are already working (usually in jobs that do not offer health insurance), seeking work, attending school, or taking care of family members. Most of those who are out of work reported facing severe health-related barriers to work, such as chronic mental or physical illness. It is not clear which Texans a Medicaid work requirement would incentivize into work who aren’t legally exempt, currently employed, or have compelling reasons for not working.
Work Requirements could do More Harm than Good
Conditioning health coverage on work activities risks directly harming the health of out-of-work enrollees and their family members instead of promoting economic self-sufficiency. Under a work requirement, people who are temporarily unable to work for health reasons would lose their access to treatments, prescription drugs, or assistive devices that could facilitate their return to the workforce. People who provide full-time care for very young, ill, or disabled family members would be compelled to balance a job alongside the demands of unpredictable, round-the-clock caretaking, an impossible scenario for many families or employers to accommodate. And at a time when Texas is trying to reverse a statewide trend of rising maternal mortality rates, low-income postpartum women who could not work after delivery would lose access to potentially lifesaving care.
Work Requirements are Complex and Costly
If the mismatch between the target population for a work requirement and Texas’ actual enrollee population is not enough to dissuade state leadership, perhaps the complexity and the price tag is. A work requirement would saddle the state with a costly administrative burden (likely at least several million dollars annually) to create, operate, maintain, and staff systems to verify employment for thousands of enrollees. State leaders would also have to invest time and effort thoughtfully designing how the work requirement will be enforced: What activities qualify as “work”? What do enrollees have to do to prove they are working? How often must someone show proof?
A viable work requirement would also have to be flexible enough to accommodate circumstances characteristic of low-wage work and poverty. For example, many low-income people move frequently, work cash-only jobs, lack control over the number of hours they work per week, have criminal histories, or lack a high school diploma, all of which could impact a person’s ability to seek, keep, and prove their employment.
The bottom line: A work requirement is not well suited to Texas' current Medicaid enrollee population, and would present a serious administrative and budgetary challenge to the state.
An earlier version of this post was originally published on The 70%. Updated and reposted with author permission.
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