As states decided for or against expanding Medicaid — and the chance to take advantage of the large incentives for doing so provided by Obamacare — there were two principal conservatives arguments for just saying no to all that federal money. The first was fiscal: The additional matching funds provided by Washington would decline over time, leaving state budgets saddled with unsustainable costs. The second was ideological. Here’s how the conservative Foundation for Government Accountability put it:
The Medicaid expansion under Obamacare moved a new class of nondisabled, childless adults to the front of the line. No longer is the program focused on kids with developmental disabilities, seniors in nursing homes, or other truly needy patients. Those who enrolled in Medicaid under the expansion are adults in their prime working years. They have no children to watch and no disabilities keeping them from meaningful employment. As a group, they have never qualified for any other forms of long-term welfare.
This latter idea — that the Medicaid expansion mostly benefitted childless deadbeats — was the source of a lot of the emotion underlying conservative hostility to the initiative, and probably also made Republicans feel less generous when it came to the fiscal risks of undertaking the expansion. No, there wasn’t much empirical support for the supposition that the bulk of able-bodied Medicaid recipients weren’t either working or looking for work. But many decades of Republican rhetoric about welfare bums conditioned today’s GOP pols to warn that the Medicaid expansion would destroy work-based welfare reform and create a new class of people willfully dependent on the government.
The Trump administration has been scratching this ideological itch by encouraging states to design waiver requests that would enable them to impose work requirements on Medicaid beneficiaries (either the “expansion population,” or those enrolled in any form of Medicaid). Kentucky has already received a waiver to do so:
The country’s first work requirement applies to Kentucky residents who joined Medicaid under the ACA, as well as traditional Medicaid beneficiaries who are not pregnant and not primary caretakers.
Lawsuits were immediately filed challenging the waiver, on grounds that it violated a Medicaid law only Congress could change. At the same time, Kentucky’s Republican governor, Matt Bevin — who campaigned on the promise to reverse his Democratic predecessor’s Medicaid expansion — signaled that he was now fine with the expansion after all, since he would be able to prevent its alleged abuse by shiftless people. (Nevertheless, he is still threatening to kill the expansion immediately if courts block the work-requirement waiver.)
This could represent a trend, with Republican state lawmakers newly rationalizing acceptance of Medicaid expansion on grounds that it will be less expensive — and less like welfare — if work requirements are allowed. The Washington Post has been examining that possibility and its mixed prospects:
Under the new rules, “we think that there may be a window of opportunity to revisit the idea of Medicaid expansion,” Utah governor Gary R. Herbert (R) said in a statement to the Washington Post. Utah has 46,000 residents who could gain insurance under Medicaid expansion, according to the Kaiser Family Foundation, although the plans being discussed would probably cover a lower number.
Utah state representative Robert M. Spendlove (R) is spearheading a plan to expand Medicaid that would impose work requirements on some residents. Spendlove has wanted to craft this kind of package for years, but says he was told by Obama administration officials that the federal government would stop an expansion proposal that included work requirements.
The Post also found interest in this approach among Republicans in Idaho, Kansas, Wyoming, and Virginia, among the 17 states that have rejected the Medicaid expansion up until now. In some states with divided partisan control of state government, such as Virginia, Democrats might not go along.
Aside from the contention that a Medicaid work requirement (as well as other closely associated “reforms,” such as charging beneficiaries premiums and higher co-pays) address a largely imaginary problem, the arguments against the requirement would be familiar to anyone who followed the “welfare-to-work” debates of the 1990s. Defining and verifying “work” isn’t as easy as it sounds; identifying the working poor might inadvertently push people now on Medicaid into employer-sponsored insurance they cannot afford. Work requirements represent a double standard, stigmatizing poor people since they are not attached to other government subsidies.
Perhaps the biggest ideological gap exposed by a Medicaid work requirement is that it treats health care as a sort of earned benefit for individuals, rather than as a fundamental right that is of inestimable social value. Shouldn’t we want everyone to have health insurance, if only to avoid the public costs of poorly treated chronic conditions that could eventually disable people and make them Medicaid-eligible under any system?
This is not, needless to say, the most common approach among Republicans; the Post found that more than a few (including governors Nathan Deal of Georgia and Dennis Daugaard of South Dakota) will continue to oppose Medicaid expansion, even if work requirements are readily available. But you can bet these and other expansion rejectionists will get in line quickly enough to impose work and other new requirements on existing Medicaid populations. So the temptation to view a leaner and meaner Medicaid as a way station to expanded coverage everywhere should be resisted for now.