the national interest

The Pathological Cruelty of Trump’s Medicaid Work Requirement

President Trump can’t repeal Obamacare, but he can still find ways to hurt the poor and sick.

Having proven itself completely unable to solve actual problems in the American health-care system, the Trump administration is setting out to solve imagined ones: Americans who are lured into sloth by free access to medical care. The administration is issuing guidance to states, allowing them to deny Medicaid to people who don’t have jobs. The goal of this initiative is “creating incentives for Medicaid beneficiaries to participate in work and community engagement activities.”

A few facts help illuminate just what the Trump administration is seeking to accomplish. The number of able-bodied, working-age Americans who receive Medicaid and who could obtain employment but choose not to is extremely small. Imposing work requirements, which entail some kind of test to determine if a recipient is employed or seeking employment as a condition of enrollment, is costly. It creates more bureaucratic hurdles, diverting funds (the overall size of which are not being increased) from coverage, and creating “enrollment denials and delays or [increasing] coverage interruptions that in turn endanger the health of people in need of medical care.”

Anybody who’s dealt with insurance knows how hassles can be draining and lead to gaps in treatment. Imagine if your insurance plan had to double as a social worker, making sure every customer was not slacking off.

Against these costs is the very slight benefit of protecting taxpayers against the scourge of lazy Medicaid beneficiaries. This is also tiny. Research on the effects of the Medicaid expansion under Obamacare has found “no significant negative effect … on employment rates and other measures of employment and employee behavior (such as transitions from employment to non-employment, the rate of job switches, transitions from full- to part-time employment, labor force participation, and usual hours worked per week).”

This is a fairly intuitive finding. You might know, or at least can imagine, somebody who would choose to stay home all day playing video games and collecting cash payments from the government. But is anybody going to stay home all day because of … free visits to the doctor?

Encouraging self-sufficiency is a perfectly valid policy objective. Attempting to apply this value to health insurance is pathological. Getting physically and mentally well is often a precondition for entering the workforce. People have trouble getting jobs because they’re unwell, not because they’re enjoying their insurance so much they don’t want to work.

Yet the pathology of seeing medical care as a privilege, and the fear that it is being extended to the wrong kinds of people, is an embedded characteristic of American conservatism. Right-of-center parties in every major democracy other than the United States accept the principle of universal health insurance. Whatever incentives they might favor to reward success or punish failure, the denial of access to basic medical care would not number among them.

The failure of Obamacare repeal was a signal defeat for American conservatism. The cruel half-measure of urging states to deny Medicaid to the unemployed indicates that, despite the defeat of their ultimate goal, the fanatical ideology that inspired it remains in place.

The Cruelty of Trump’s Medicaid Work Requirement