At a Crossroads: Medicaid and Health Policy in the U.S.

This post is a part of our Bioethics in the News series

By Hannah Giunta, DO, PhD, MPH

Recently, U.S. states were granted federal permission to pilot a variety of initiatives that will require able-bodied, adult Medicaid recipients to attend school, work, volunteer, or participate in rehabilitation to receive benefits. Earlier this month, Kentucky became the first state to successfully apply for a waiver allowing them to trial work requirements. While the majority of Medicaid recipients—including children, enrollees with disabilities, and full-time caregivers—are exempt from these changes, the initiation of a work requirement represents a dramatic shift in health policy unprecedented in our nation’s history. While I am not opposed to work requirements for cash assistance, access to health care is a fundamentally different matter. Even if the work requirement could be implemented without negative downstream effects, it still values people’s lives according to what they contribute.

When Medicaid was first signed into law as part of the 1965 Social Security Act by President Johnson, it represented the culmination of a larger social debate about poverty and health. A general consensus emerged that no American should be left without access to needed medical care whether due to age, disability, or disadvantage. Against the backdrop of Johnson’s “War on Poverty” and “Great Society” initiatives, access to health care was rightly seen as a crucial factor in economic empowerment and development. Johnson stated unequivocally in his January 1964 State of the Union address to Congress:

This budget, and this year’s legislative program, are designed to help each and every American citizen fulfill his basic hopes—his hopes for a fair chance to make good; his hopes for fair play from the law; his hopes for a full-time job on full-time pay; his hopes for a decent home for his family in a decent community; his hopes for a good school for his children with good teachers; and his hopes for security when faced with sickness or unemployment or old age. (Peters and Woolley, The American Presidency Project)

But, there was also a sense that America could do right by the poor and disadvantaged. Later in the same State of the Union address, Johnson stated:

This administration today, here and now, declares unconditional war on poverty in America. I urge this Congress and all Americans to join with me in that effort. It will not be a short or easy struggle, no single weapon or strategy will suffice, but we shall not rest until that war is won. The richest Nation on earth can afford to win it. We cannot afford to lose it. (Peters and Woolley, The American Presidency Project)

Thus, from the very beginning, the Medicaid program was justified based on the importance of economic empowerment and also on the basis of the compassion and decency a rich nation ought to show its citizens. In its present forms, the work requirement will go a long way toward undermining both of these justifications.

From the perspective of economic empowerment, one of the major arguments made in favor of the work requirement emphasizes personal empowerment through work. As Seema Verma, head of the Centers for Medicare and Medicaid Services, reiterated in her public comments, community involvement through work can be a source of empowerment and possibly help recipients transition to jobs with health benefits. Yet, while Americans certainly want good jobs with benefits, current work requirement proposals do little to help Medicaid recipients climb the economic ladder. There is no additional funding for education, workforce placement services, or incentives for companies to hire these workers at a living wage. It is unclear how simply requiring people to find jobs improves the situation. Of course, some might argue that people should take any 20-hour per week job they can find if they want benefits. While you can make an argument in favor of this proposition, you cannot simultaneously herald work requirements as a force for economic empowerment. Workers are likely to end up in the same dead-end jobs available before the work requirement. Additionally, with no upgrade of their skills or qualifications, I imagine the likelihood of them obtaining a job with decent health insurance coverage is the same as it is right now. The only difference is that now workers who lose a job and cannot find new employment lose their health insurance too. If they volunteer, we as a society might benefit from these workers’ efforts. But, though volunteering is laudable, it is unlikely to result in a major step up on the economic ladder and places further burdens on individuals who are already on the margins.

Not to mention, the work requirement may paradoxically exacerbate the health inequities Medicaid was designed to address in the first place. For instance, children, pregnant women, and full-time caregivers make up a large number of Medicaid recipients. They are currently exempt from the work requirements, but their family members are not. Imagine how much more hardship a family will face if a partner or parent loses coverage. Adult caregivers and children may be forced into a losing battle between their own needs and the needs of the newly uninsured family member.

Most crucially, the issue at stake in this debate is truly whether health care is a human right or a commodity provided or traded to those who contribute something in return. Of course, supporters of the work requirement will point out that they merely want those enrollees who can work to contribute something in exchange for free benefits. It is human nature to count the cost of our generosity. However, in a society as rich as our own, should anyone go without needed care? Is the life and health of an individual who has not held a job in years worth less than the life of someone who works 20 hours each week? According to the work requirements, it seems like the answer is a resounding “yes.” Of course, the person could seek care at the emergency room—a place of last resort for many people without resources. But, can’t we do better than that? The question really becomes: can the United States care for its own, or has the most powerful nation in history lost its way? We can decide to declare defeat or we can develop new battle strategies to win the war on poverty once and for all. How we answer this challenge will undoubtedly determine how future historians look back on this time.

Hannah Giunta, DO, PhD, MPH, is a first year pediatric resident at Mayo Clinic and proud alumnus of Michigan State University. She completed her PhD in spring 2016 under the direction of Dr. Tom Tomlinson and her medical degree in May 2017.

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1. Alonso-Zaldivar, R. (2018, January 12). Trump work requirement rewrites health care rules for poor. Associated Press. https://apnews.com/5c2353e241d94aaf85a2944b572feb5e.
2. Goldstein, A. (2018, January 12). Kentucky becomes the first state allowed to impose Medicaid work requirement. The Washington Post. https://www.washingtonpost.com/national/health-science/kentucky-becomes-the-first-state-allowed-to-impose-medicaid-work-requirement/2018/01/12/b7b56e3e-f7b4-11e7-b34a-b85626af34ef_story.html?utm_term=.1f82f99c356c.
3. Lyndon B. Johnson: “Annual Message to the Congress on the State of the Union.,” January 8, 1964. Online by Peters, G. and Woolley, J.T. The American Presidency Project. http://www.presidency.ucsb.edu/ws/?pid=26787.