Medicaid, a joint federal and state health program for the poor, allows states to seek waivers from the federal government to create work requirements. As of February 2019, six states had received approval for work requirement waivers, eight state programs were awaiting approval and one state waiver was facing legal challenges in court, researchers reported April 1 online in Health Affairs.1
Proponents of Medicaid work requirements maintain that benefits are only meant to be temporary and that employment will help people move out of poverty. Opponents argue that cutting off benefits for people too sick to work prevents them from getting healthy enough to hold down jobs.
“It’s well known that Medicaid enrollees overall have higher burden of physical and mental health problems than the general population,” said study co-author Brendan Saloner, PhD, of the Johns Hopkins Bloomberg School of Public Health, Baltimore.
“What our study adds is new information showing that among the Medicaid population that is likely to be subject to work requirements, there is likely to be greater burden on those with physical and behavioral health conditions,” Mr. Saloner says by email.
“It underscores that any attempt to implement work requirements will need to confront the reality that many of the people who are likely to risk losing their coverage have significant health needs that likely prevent them from working,” Mr. Saloner adds.
For the study, researchers examined data from the National Survey on Drug Use and Health for the period 2014 to 2016.
Compared with Medicaid enrollees without any identified health conditions, people with either serious mental illness, substance use disorders, or both problems were much more likely to have worked less than 20 hours a week in the previous week. States with Medicaid work requirements typically require at least 20 hours of week of work, job hunting or school.
Just 23% of people with serious mental illnesses worked at least 20 hours a week, while only 43% of people with substance use disorders achieved this minimum number of work hours. Among individuals with both mental illness and substance use issues, only 32% worked at least 20 hours a week.
By comparison, almost half of Medicaid enrollees without any identified health problems worked at least 20 hours a week.
Very few unemployed Medicaid enrollees reported not looking for work or not wanting a job, the study found.
But people with behavioral health problems were more likely than those without health conditions to report they were too disabled to work, and they were also less likely to be looking for work.
The study wasn’t a controlled experiment designed to prove whether or how specific health problems might influence how many hours Medicaid enrollees worked.
“Chronic health issues can limit an individual’s employment options due to physical or mental barriers to performing certain tasks,” says Ann Sheehy, MD, MS, a researcher at the University of Wisconsin School of Medicine and Public Health, Madison, who wasn’t involved in the study.
“Individuals with chronic health problems may also need to attend frequent medical appointments,” Dr. Sheehy says by email.
Health issues can make it harder for people to find jobs and keep them, says Olena Mazurenko, MD, PhD, MS, of Indiana University-Purdue University Indianapolis.
“We need to conduct more detailed inquiries to examine the underlying reasons for why Medicaid enrollees with chronic conditions are unable to work,” Dr. Mazurenko, who wasn’t involved in the study, says by email.
Work requirements may be unreasonable for a significant percentage of Medicaid enrollees, many of whom suffer from debilitating health conditions, says Kumar Dharmarajan, MD, MBA, chief scientific officer at Clover Health and an assistant professor at Yale School of Medicine in New Haven, Conn.
“States need to create and implement standardized criteria to identify these individuals and exclude them from work requirements,” Dr. Dharmarajan says by email. “Not doing so may result in loss of Medicaid coverage, compromised health care access, and unnecessary suffering.
- Wen H, Saloner B, Cummings JR. Behavioral and other chronic conditions among adult medicaid enrollees: Implications for work requirements. Health Aff (Millwood). 2019 Apr;38(4):660–667.