Even as the Trump administration greenlights state-imposed work requirements for “able-bodied adults” receiving Medicaid benefits, five states are asking for the power to take a much bigger step toward treating Medicaid like “welfare”: imposing arbitrary lifetime time limits on benefits for politically disfavored categories of recipients.
As you may recall, the 1996 welfare reform legislation imposed five-year time limits on benefits, signaling the transformation of cash assistance from a “safety net” income maintenance program to “Temporary Assistance for Needy Families,” or TANF, welfare’s new moniker. In retrospect, this and other provisions represented the beginning of the end of cash assistance as a significant anti-poverty tool in many states. It’s reasonably clear that importing time limits from TANF to Medicaid has the similar intention of indirectly killing off the Affordable Care Act’s Medicaid expansion, by radically curtailing benefits for the low-income childless adults without health insurance that were its main target.
If it’s unclear Medicaid work requirements will pass legal muster (they are already under attack in the courts on grounds that they violate the basic laws governing the program), the legality of time limits is even more dubious, despite the administration’s broad powers to grant waivers to let states “experiment” with ways to achieve program goals. Since the 2010 expansion clearly made childless adults eligible for Medicaid, it’s hard to argue quickly taking benefits away (one state, Kansas, wants a 36-month limit) as though the beneficiaries don’t really deserve them was part of the legislative design. It’s also not clear the administration is going to approve time limits, though one unhappy progressive observer gave approval a “50-50 chance.”
More generally, the conservative effort to treat Medicaid like welfare reflects a shrewd if immoral attempt to stigmatize certain Medicaid beneficiaries as people who ought to become “self-sufficient.” Unlike work requirements, time limits would not be discharged by the act of getting a job. Indeed, the idea is that once gainfully employed, the able-bodied would then be able to get health insurance on their own or through their employers. That’s far from true, of course, as evidenced by the high uninsured levels among the working poor before the ACA was enacted. But that fact simply reflects the deeper reality that Republicans tend to view access to health insurance not as a fundamental right, but as a job perk or an individual spending decision.
For most progressives, of course, access to Medicaid for able-bodied people is a natural stop on the road to universal government-provided (or government-guaranteed) health insurance. It’s in no way intended to be “temporary,” much less subject to strict time limits. And its relationship to work, for that matter, is incidental, not central; people don’t typically decide to work or not work specifically for health coverage, and many who do work don’t get health coverage anyway. Given the unstable nature of the individual market segment of Obamacare (and the policies governing it), the Medicaid expansion is now looking like the most successful part of the Affordable Care Act, despite the Supreme Court making the expansion a state-by-state option that still leaves larges portions of the country uncovered.
So conservative state efforts to impose work requirements and especially time limits should be seen for what they are: an ancillary attack on the Medicaid expansion (understandable given the congressional Republican failure to phase it out last year), and for that matter, on the idea of universal access to health insurance. If the administration approves Medicaid time limits, the battle for the future of the American health-care system will reach a new level of intensity, even if Team Trump leaves the laws governing Obamacare alone for the time being.