In a letter to state Medicaid directors Thursday morning, the Trump administration announced that it would allow states to require Medicaid recipients to participate in a work program or other form of approved “community engagement” in order to retain their health benefits. While there will supposedly be exceptions for disabled people, allowing states to implement the work requirement is a terrible idea. As a disability lawyer and disabled person myself, I know this policy change will be disastrous for my community in a number of important ways.
My first concern involves the eligibility process. According to the Washington Post, states will be able to decide for themselves who qualifies as “disabled” for the purpose of being exempt from the work requirement. No matter how broad they define the category, there will be disabled people who do not qualify for the exemption even though they should.
I know this from experience. Indeed, in my role as an appeals lawyer for people applying for social security disability, I often deal with similar problems. The Social Security Administration acknowledges that its standard for social security disability eligibility is “very strict.” Many people who eventually do qualify for benefits have to go through several appeals that can take years. And even if the standard for Medicaid work-requirement exemption is much more lenient than the standard for social security, it still grants the state a mechanism requiring people to fight for coverage they should be entitled to.
As a disability lawyer and disabled person myself, I know this policy change will be disastrous for my community.
While this appeals process plays out, people are likely to get sicker and more disabled as they await a final decision. In the end, many people could become stuck in a grey area: too sick or disabled to work, but not sick or disabled enough to be exempt from the work requirement. Barring the possibility that they find an employer sympathetic to his or her special needs, the only way to get out of this in-between space is to eventually become sick or disabled enough that they are eligible for Medicaid. By that time their health care will be much more expensive to the state (if they survive that long).
Such an inherent Catch-22 is remarkably cruel. Getting exempted from the work requirement due to disability will almost certainly require some kind of doctor’s note or documentation. However, if you don’t have insurance, going to the right doctor (or any doctor at all) can be difficult. And as a result, you won’t be able to get the documentation needed to become exempt.
This will be compounded if you don’t have the type of disability that can be easily and quickly diagnosed, such as mental health disabilities or other invisible illnesses. For example, my autoimmune illnesses took years of testing and specialist visits to be diagnosed. If I were reliant on Medicaid in a state with a work requirement, I would have had to pay for years of testing and doctor appointments myself before I finding a doctor willing to sign off on a work exemption. People whose income allows them to be eligible for Medicaid almost certainly cannot afford these upfront costs.
The change in policy will also exacerbate health inequalities that are already a massive national problem. Medicaid is a means-based program, meaning that only low-income people (the income cut-off varies by state) will be affected by these changes. An increase in the access requirements, no matter what those requirements entail, will necessarily reduce the number of people who are able to access Medicaid. Any additional requirements will serve to make people who are currently eligible for Medicaid ineligible. In other words, less low-income people will have access to healthcare so more low-income people will have even worse health outcomes.
The change in policy will also exacerbate health inequalities that are already a massive national problem.
The states that will end up implementing these work requirements are also the states that tend to be the poorest to begin with, such as Kentucky (the fourth poorest in the country) and Arkansas (the sixth-poorest), furthering the unconscionable poverty and negative health outcomes associated with it.
If this seems like déjà vu, that’s because it is. In 1996, President Bill Clinton signed the Personal Responsibility and Work Opportunity Reconciliation Act. The law overhauled America's so-called welfare program and included a new work requirement similar to the one being discussed here. This had devastating consequences for the most vulnerable because as access to benefits decreased, extreme poverty increased. These negative outcomes will happen again with the Medicaid work requirement, except on top of poverty, untreated health conditions will also likely drive worsening health outcomes — up to and including death.
It doesn’t take a political scholar to understand that this is yet another attempt by the Trump administration to eliminate the modest gains in health insurance coverage made by the Affordable Care Act. Around 60 percent of working age non-disabled recipients of Medicaid are employed. The addition of a work requirement moves us further away from the idea of health care as a right and towards an America that does not provide a safety net for the most vulnerable, including people with disabilities.
Katie Tastrom is a writer, attorney and activist in Syracuse, New York. Her work has been published at Slate, Ravishly and Everyday Feminism, among others. She especially loves writing about living with chronic illness. See more of her work at katietastrom.com.