For weeks, Republicans in Congress have haggled over cuts to Medicaid, the health care program for the poor. Some lawmakers see an opportunity to offset the cost of extending $5 trillion in tax cuts, a priority for the White House. Others worry their constituents will lose access to critical care.
Of the myriad proposals that have been floated, one has broad support within the party: imposing work requirements for some Medicaid enrollees. It’s a key feature of the sprawling tax bill that passed in the House and could in theory save $280 billion over a decade.
Asking recipients of government benefits to work, seek employment, find training programs, volunteer or attend school isn’t unreasonable. Although more concessions could be made for job seekers, the policy is broadly targeted at encouraging able-bodied adults under 65 to become self-sufficient, with exemptions for those who’d struggle to do so, including parents with dependent children and people seeking treatment for substance-use disorders. More than 60% of Americans support the idea.
The challenge is implementation. The House bill passed with work requirements starting in 2027. Yet such rules are devilishly complex to administer. The bureaucracy needed to confirm eligibility is costly; the available technology is often outdated; some determinations are unavoidably subjective; and communicating new rules to an itinerant population with brisk job turnover is a challenge, to say the least.
The task of generating savings — without simply snatching benefits from the vulnerable — will require upfront investment and meticulous planning. Rushing will virtually guarantee avoidable coverage losses, possibly beyond the 8 million currently projected from cuts overall.
If the Senate goes ahead with this plan, it must try to mitigate such risks. Previous efforts along these lines offer valuable lessons. In 2018, Arkansas became the first state with an approved waiver to test work requirements in their Medicaid programs. More than 18,000 residents were cut from the state’s Medicaid rolls, many of whom remained eligible. (The program was eventually halted by a district court, which found that federal health officials failed to adequately consider coverage losses.)
The dismal outcome wasn’t for lack of trying. State officials sent 900,000 letters and emails, contracted with call centers, and placed ads on local TV and radio stations — spending more than $20 million on IT systems, beneficiary outreach and data analysis. Despite these efforts, Arkansas residents say they were either unaware of the changes or confused by the new requirements.
Avoiding Arkansas’ mistakes will require serious investment. For starters, as with other eligibility checks, states should rely on data they already have, including pay stubs, tax returns and information from other assistance programs, while minimizing paperwork for beneficiaries. Much of the documentation needed for work verification is submitted to the state by employers; ensuring state officials can match data across programs will require upgrading sclerotic IT systems. Officials should lean on the managed-care organizations that administer plans for cross-checks.
More standardized data, meanwhile, should allow for automation, freeing up limited staffing for more subjective adjudications, including checks for informal workers with inconsistent income. Better analytics could enable state officials to monitor unusual drops in enrollment or target populations that might fall through the cracks. Giving those who no longer qualify a gradual off-ramp — and help finding alternative coverage — will be essential.
As things stand, the administrative demands of a work requirement are such that the projected savings may prove exaggerated or indeed illusory. Investment in a data-driven overhaul of this kind should improve the chances of success while minimizing disruption. It might even help the broader Medicaid system deliver benefits more efficiently. States should start small, conduct robust studies and correct course as needed.
Historically, objections to work requirements have been more practical than philosophical. Republicans have an opportunity to show this effort is motivated by something more than cynicism. Rushing through reform is the surest way to doom their chances.
— Bloomberg Opinion via TNS
