The gendered effects of Medicaid work requirements

In January 2018, the Center for Medicare and Medicaid Services (CMS) announced that it would allow states to require employment as a precondition to Medicaid eligibility. While unsurprising, considering the Trump administration’s constant maneuvers to undermine universal healthcare, this is the first time CMS has endorsed such a program. Several conservative states have already pounced on this opportunity: Arizona, Arkansas, Indiana, Kentucky, Michigan, New Hampshire, Ohio and Wisconsin. Several more states have submitted requests to implement work requirements, which are now pending.

As Medicaid is a joint federal/state program, states must adhere to certain guidelines, set forth in the Social Security Act. However, they are authorized under §1315 of the Act to waive some of its provisions in order to implement experimental, or pilot, programs. Many states have used this authority to provide broader coverage through these special programs (e.g., expanding Medicaid eligibility to include nonelderly adults, children with disabilities, HIV-positive individuals, etc.). Unfortunately, states are also empowered to adopt restrictive measures, such as work requirements.

These work requirements differ in scope, but generally mandate that beneficiaries of Medicaid spend 80 hours per month, or 20 per week, on either paid employment or other “qualifying activities,” such as school, volunteer work or job training. Failure to participate in and report these activities will result in loss of Medicaid eligibility (though this is done differently in the various states). In Arkansas, for example, if a beneficiary fails to report sufficient work activities for three months, they will be “locked out” of Medicaid for the remainder of the calendar year.

The tragic results of these programs are already becoming apparent in states such as Arkansas, which requirement went into effect in June 2018. As of March 2019, over 18,000 Medicaid beneficiaries in Arkansas had lost their healthcare for failure to comply with the reporting requirements. Of those, only about 10% have since reapplied and regained coverage in 2019.

This clearly impacts numerous marginalized people, considering factors such as rurality, computer literacy and English proficiency. It is also, of course, a gendered issue. This is largely due to the demographics of those most likely to live in poverty and face barriers to consistent employment. While many groups are disproportionately harmed, this post will focus on the challenges that women in particular face in complying with work requirements.

First, single mothers account for most of the low-income adults who qualify for Medicaid. These women often work part-time jobs with inconsistent hours in order to care for their children (or because these are the only jobs available). In industries like food service and retail, hours vary from week to week and offer little flexibility, so missing work for any reason may result in job loss. Due to this instability, gaps in employment are common for low-wage workers. However, in some states, failing to meet the work requirement even for one month can result in the loss of healthcare.

Significantly, women are more likely than men to be responsible for caring for children, which impacts their availability to work. While all states have some form of an exemption for parents of dependent children, Indiana only exempts parents of children under the age of six. Even exempting parents of all minor children is arguably still insufficient, considering that for a child with special needs, age may not be relevant to the level of care needed.

Additionally, women often care for incapacitated family members who are not their children. The states’ exemptions do not sufficiently address this situation either. For example, Kentucky only exempts primary caregivers to a dependent if the dependent lives in the same household. It also limits the number of people who may claim this exemption to one per household, again failing to contemplate myriad circumstances. A Medicaid beneficiary in Arkansas reported that caring for her parents restricted her to looking for work in the evenings, which was difficult to find.

Practically, exemptions offer little protection for some of the most marginalized groups. Although some states automatically exempt beneficiaries through their own data, such as those already fulfilling another social program’s work requirement, or those known to have young children or a medical condition, they overlook many others. This puts the burden of identifying and reporting an exemption on the Medicaid recipient. Even if a someone qualifies for an exemption, she may not know that she does, or how to report it to the state (which is why even broadening exempted categories is not an ideal solution either).

Looking ahead, there may be hope that these requirements will not gain traction. Already, the D.C. Circuit Court has blocked Kentucky’s program twice, and just vacated the approval of Arkansas’s as well. In these rulings, it emphasized that the Secretary of Health and Human Services is not considering how these programs promote the goals of Medicaid, namely, providing medical care. This rationale finds strong support in similar prior cases where states attempted to implement restrictive requirements solely to save money. Hopefully, this provides a temporary remedy for those who might otherwise lose their healthcare, though it comes late for many in Arkansas who already have.

The Supreme Court could resolve this issue by ruling work requirements impermissible as a precondition for Medicaid. Yet, even if the court does grant cert, its current conservative composition might result in a stamp of approval for work requirements. It remains to be seen whether the government will take any further action.