A so­lu­tion in search of a prob­lem

The White House’s move to al­low states to have work re­quire­ments for Med­i­caid is su­per­flu­ous and harm­ful.

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IN CON­TRAST with those of other ad­vanced in­dus­trial democ­ra­cies, es­pe­cially in Europe, the U.S. sys­tem of so­cial in­sur­ance and in­come sup­port dis­trib­utes ben­e­fits based not only on mem­ber­ship in so­ci­ety, but also on work ef­fort, past and present. In the realm of health in­sur­ance, this means that in­stead of adopt­ing univer­sal cov­er­age as a na­tional le­gal stan­dard, then de­vis­ing a uni­tary sys­tem to meet that goal, the United States cob­bled to­gether pro­grams whose or­ga­niz­ing prin­ci­ple, such as it is, is work. A plu­ral­ity of adults get tax-sub­si­dized in­sur­ance through their em­ploy­ers; most re­tirees get Medi­care, paid for out of de­duc­tions from their past pay­checks. Many oth­ers — poor chil­dren, peo­ple with dis­abil­i­ties — ob­tain in­sur­ance from pro­grams whose premise is that the re­cip­i­ents are nei­ther ex­pected nor able to work, which is it­self a work-re­lated cri­te­rion.

This makes no ac­tu­ar­ial sense, be­cause the need for health care and work are not nec­es­sar­ily con­nected. It cre­ated the im­ped­i­ment to worker mo­bil­ity known as “job lock.” And it cre­ated a large and chronic cov­er­age gap for work­ing-age, nondis­abled adults who lacked jobs, or whose em­ploy­ers did not pro­vide in­sur­ance but paid their em­ploy­ees too lit­tle for them to buy it on their own.

Oba­macare tried to fill that gap — and break the link be­tween work and in­sur­ance — by open­ing up a sub­si­dized in­di­vid­ual mar­ket and by ad­mit­ting mil­lions of work­ing-age adults to Med­i­caid. This was progress, both ide­o­log­i­cally and sub­stan­tively. And now the Trump ad­min­is­tra­tion pro­poses to un­der­mine it by al­low­ing states to re­quire nondis­abled adults to work for Med­i­caid ben­e­fits hereto­fore pro­vided based on only in­come.

This is a so­lu­tion in search of a prob­lem. The ma­jor­ity of the tar­get pop­u­la­tion al­ready work (60 per­cent) or live with a worker (79 per­cent), ac­cord­ing to the Kaiser Fam­ily Foun­da­tion. So even if the of­fi­cial ra­tio­nale for the new pol­icy — the De­part­ment of Health and Hu­man Ser­vices says work im­proves health — is valid, it’s su­per­flu­ous in most cases. Of those who aren’t work­ing, many have care-giv­ing re­spon­si­bil­i­ties that ei­ther they would have to aban­don or states would have to ac­cept as the equiv­a­lent of work out­side the home, af­ter a lot of com­plex and ex­pen­sive ad­min­is­tra­tive has­sle.

Eight states have pe­ti­tions pend­ing for the rel­e­vant le­gal waiver that would al­low them to im­pose work re­quire­ments. Of th­ese, five ex­panded Med­i­caid through Oba­macare, so the nec­es­sary ef­fect would be to tighten el­i­gi­bil­ity for that pop­u­la­tion, end­ing cov­er­age for at least some poor peo­ple who have it now. (A waiver for Ken­tucky, also an ex­pan­sion state, has just been ap­proved.) Of the other states that did not ex­pand Med­i­caid, the new pol­icy would, in some cases, add to ad­min­is­tra­tive bur­dens with­out af­fect­ing work in­cen­tives for any­one ex­cept a rel­a­tive hand­ful of non-dis­abled adults.

And, of course, peo­ple who can’t meet a work re­quire­ment will not cease seek­ing med­i­cal care; they will get it as they used to be­fore Med­i­caid, by show­ing up at emer­gency rooms, where they must be treated, of­ten at higher ex­pense than would have been the case if they had in­sur­ance.

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