When I hear pundits going on about the Medicaid work requirements, I think of my father.
He has worked in the United States for twenty-four years, taking on the role of a handyman, migrant farmer, truck driver, construction roofer, dialysis patient transporter, and elder transporter. His limited English and third-grade education land him in low-paying jobs with limited hours and an oversupply of workers — resulting in frequent periods of unemployment.
For 17 years, these moments of turmoil were partially assuaged by Medicaid. No job or scant hours meant little to no income, and in turn, health insurance. A safety-net system provided us with a lending hand during years of trepidation.
Today, several states including Kentucky, Indiana, Arkansas and New Hampshire plan to implement a system that would turn its back on people like my father and deem them ineligible for Medicaid while unemployed. It’s no surprise that most Democrats oppose Medicaid work provisions, citing projected public insurance losses of up to 15% state-wide.
But Republicans are not entirely wrong for supporting work requirements. The provision has led some Republican lawmakers from non-expansion states to consider expanding Medicaid. The problem arises when states vow to mandate work without addressing job-related barriers.
With proper mitigation strategies, low-income residents from states unwilling to previously expand Medicaid will gain health insurance, while those in expansion states will benefit from provisions addressing the difficulties of stable job attainment. To aid in doing so, the following sections outline job-related barriers.
Financial limitations preclude job-seeking behaviors. Medicaid beneficiaries are ten times more likely to cite transportation barriers when compared to their privately insured counterparts. Currently, states are required to transport certain Medicaid beneficiaries under the Non-Emergency Transportation (NET) program. But states like Iowa and Indiana are beginning to utilize Section 1115 NET time-limited waivers to limit transportation services.
Additionally, Indiana, Iowa and Kentucky hold rights to cut transportation services, while others look to waive NET for adults above 101-138% FPL. Under such conditions, people unable to afford housing in urban areas are less likely to find a doctor, resulting in worse health and fewer job options.
Another limitation that stymies job searching is intimate partner violence (IPV). 1 in 3 women and 1 in 4 men have been victims of IPV. Severe cases are often characterized by a controlling partner denying the victim a normal work-life balance. Compulsory 20-hour work weeks become unsustainable and would result in a loss of health insurance if work is mandated. Furthermore, since women are disproportionately affected by IPV and are more likely than men to utilize Medicaid, their coverage might heavily suffer.
Some individuals are simply lackluster to find a state-mandated Medicaid qualifying job. For example, some women in my parents’ social circle clean homes for a living. Near minimum-wage payments sustain them and their children. They have no incentive to leave a flexible job. Work provisions ignore this area of our part-time workforce, making it prudent for legislators to revisit the 20-hour work week mandate.
On top of job-searching hardships, poor dental care, language barriers, low education status and criminal records forestall employment once a Medicaid beneficiary fills out an application.
Adults below 100% FPL are more likely to have dental complications than those with incomes above 200% FPL. This finding is alarming since a study found that persons with ideal smiles are more likely to earn a job than those with non-ideal teeth. In other words, people required to work for health care face prejudice and an ingrained disadvantage.
Language barriers encompass another obstacle. For instance, 38% of Latinxs report Spanish-speaking predominance, suggesting that over a third of Latinxs on Medicaid might face hiring difficulties in our English-dominated economy. Arizona, a state seeking a work waiver, should be wary of losses in Latinx coverage since 54% of their nonelderly Medicaid recipients identify as Latinx. Other states pursuing work waivers with significant numbers of Latinx beneficiaries include Kansas (19%), Utah (16%), and Wisconsin (19%).
Demanding work from populations with low rates of higher education is unfair because financially disadvantaged groups were not always afforded equal educational opportunities. Institutional injustices historically impaired their ability to attain education and subsequent work. Some might even find themselves in a cycle of rejection at low-level jobs. Indeed, after high school, I could not find work at local fast-food chains due to inexperience and a high supply of similarly qualified applicants.
Although imperfect teeth, poor English and little education are amenable to change, a criminal record is less malleable. As of 2010, 3% of the U.S. population served time in prison, whereas 8% had a felony conviction. Removing criminal records alleviates the stigma these individuals face on the job market, but expungement is often limited to misdemeanors and juvenile offenses. Ex-convicts consequentially become some of the least desired workers.
Unsurprisingly, over three-quarters of former inmates report that earning a job is nearly impossible. About two-thirds remain unemployed or underemployed 5 years after serving time. The entrenched hesitancy to hire ex-convicts urges us to rectify a work-for-health system.
Even if an able-bodied Medicaid recipient is hired, job maintenance becomes a formidable challenge. As mentioned above, low-income populations find difficulties in maintaining a job. Residents in states with work provisions who face situations similar to that of my father’s will face uncertainty, joblessness and a resultant loss of health insurance.
Outlining the complexity of varied job barriers aimed to expose unpromising work-provision outcomes if not enhanced by job barrier mitigation. Past mishaps and forthcoming losses in coverage necessitate analyses on the provisions’ detrimental effects, followed by solutions to circumvent job barriers. Research detailing job searching, job earning and job maintaining barriers is necessary if work provisions are to actualize.
Ensuing revelations will urge states to help Medicaid work under the adage that good health precedes work, not under the pretense of the converse. Acknowledgment and acceptance of the former might save the program’s fundamental goal of providing health care to America’s most vulnerable populations.
David Velasquez is a medical student.
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