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America’s Medicaid work requirement paradox, explained by 2 polls

Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

The Trump administration is moving full speed ahead on Medicaid work requirements: On Friday, the Centers for Medicare and Medicaid approved Indiana’s request that allows the state to revoke coverage for people who don’t meet certain employment or job training standards. Two states have now received approval with more to come.

There is a conventional wisdom that, even as Medicaid has shown its political resilience, the public is pretty open to work requirements. But some new polling, shared exclusively with Vox, complicates that picture.

The liberal Center for American Progress (CAP) released a poll on Republican proposals to cut Medicaid and other safety-net programs. They found that, broadly, any plans to cut government welfare spending are unpopular:

  • 80 percent of Americans said they opposed cutting Medicaid,
  • 78 percent said they opposed cutting Social Security disability insurance,
  • 66 percent said they opposed cutting food stamps.

You get the idea.

(Consider the source, of course. These are the details on the CAP poll: 2,350 registered voters, weighted to reflect national demographics, surveyed online late last month. It was conducted by GBA Strategies.)

According to the CAP poll, the public isn’t enamored with Medicaid work requirements either: 57 percent said they opposed allowing states “to deny Medicaid health coverage to recipients ages 18 to 64 who do not have a job with a certain amount of hours and do not participate in state-approved work programs.”

That finding sort of shocked me, because we’ve seen other polling recently that suggested Americans were on board with work requirements. The Kaiser Family Foundation (KFF), the gold standard of health policy polling, found in June that 70 percent of respondents said that they would support a work requirement.

There are a couple of ways to reconcile those findings. First, the Kaiser survey came out when there were other bigger health care stories in the news; CAP’s poll arrived on the heels of a big Medicaid work requirement announcement, which was likely accompanied by critical news coverage.

But I’d look at the wording of the questions. KFF asked about allowing states to impose work requirements on people “in order to get health insurance through Medicaid.” CAP asked about denying people health insurance if they didn’t meet the requirements set by their state.

I’m not a pollster and I’m not interested in litigating which is the more appropriate question. KFF is the gold standard for a reason. But I think this disparity — a huge majority supports work requirements if you frame them one way; a solid majority opposes them if you use a different frame — is telling in the odd relationship Americans have with the social safety net.

On the one hand, we believe in work — Max Weber’s Protestant work ethic is so crucial to understanding the American psyche for good reason. Work is treated as an inherent good. That might help explain why we collectively are so susceptible to stories about people taking advantage of Medicaid or disability insurance, even if there isn’t evidence of a pandemic of fraud.

But on the other hand, Americans do believe in a social safety net. According to the CAP poll, more than 70 percent of people said they opposed cutting home heating assistance for low-income Americans, unemployment insurance, and affordable housing programs.

Medicare and Social Security have long been third rails of American politics. Medicaid may have joined them after Republicans proved unable to overhaul it during the Obamacare repeal debate. We aren’t a European social democracy by any stretch, but there is a consensus that we should support the least advantaged among us.

So the way these issues are framed is key. Americans are okay with requiring work as a principle — though, as we’ve covered, there don’t seem to be many people on Medicaid who can work but aren’t. But if you then explain the consequences in vivid terms, that people could be denied health insurance as a result, they’re less comfortable with it.

This is something to keep an eye on as House Speaker Paul Ryan looks to keep welfare reform alive.

Ryan, as the Wall Street Journal reported over the weekend, is looking to reframe the debate as “getting people the skills and opportunities to get into the workforce.” That is the kind of rhetoric, as this Medicaid polling suggests, that can get Americans onboard.

But if the actual result is funding and enrollment cuts — and people understand that — these proposals rapidly become much less popular.

This story appears in VoxCare, a newsletter from Vox on the latest twists and turns in America’s health care debate. Sign up to get VoxCare in your inbox along with more health care stats and news.