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These are the people who would lose under Medicaid work requirements

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.

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We just got some of our strongest evidence yet that there is no pandemic of Medicaid enrollees who are avoiding work to stay on the program's rolls, even as the Trump administration prepares to institute work requirements in some states that have requested them.

The research, conducted by the University of Michigan and published on Monday in JAMA, looks at the work status of people who enrolled in Medicaid after Michigan expanded the program under Obamacare. It stands out for being based on interviews with Medicaid enrollees, rather than on administrative data or other information.

The big-picture takeaway is: Most Medicaid enrollees in Michigan were working already, unable to work, or at a point in their lives where they would not work (retired or a student). Almost three-fourths of the people in the study fell into those categories.

Nearly half of the Michigan Medicaid enrollees were working. Another quarter were either unable to work or were retired, in school, or acting as a homemaker.

It was only the yellow bar (27.6 percent) who were "out of work" — not working but would work. Those are the people we might reasonably expect to be affected by a work requirement. The proposals from states like Wisconsin to institute such a mandate usually make allowances for the Medicaid enrollees who are in school or have a disability that stops them from working.

When you break down the "out of work" population, based on the Michigan survey, you don't really get a picture of lazy hangers-on. Instead, you see people with real barriers to working — and who might benefit from having health insurance.

  • Two-thirds said they had a chronic physical illness.
  • 35 percent said they had been diagnosed with a mental illness.
  • One-quarter said they had a physical or mental condition that interfered with their ability to function at least half of the time.

The Trump administration has defended work requirements, proposed by at least six states this year, using rhetoric about the dignity of work.

“CMS believes that meaningful work is essential to beneficiaries’ economic self-sufficiency, self-esteem, well-being, and health of Americans," Trump health official Seema Verma said last month.

But these findings, which track with other research we've seen, raise questions about the practical value of these requirements. Most Medicaid enrollees, it seems, already are working or can't reasonably be expected to work.

And of the population that might seem like the logical target of a work requirement, most have significant physical or mental health needs — so why would we want to institute a policy that could lead to them losing health insurance?

“The question raised by these data for states is — is it worth the cost to screen and track enrollees when only a small minority isn’t working who are potentially able to work,” Dr. Renuka Tipirneni, lead author of the Michigan study, said in a statement.

She continued:

Even if they don’t meet federal disability criteria, our survey shows many of these individuals face significant health challenges. It’s also important to consider that dropping them from coverage for failure to fulfill a work requirement could seriously impact their ability to receive care for chronic physical and mental health conditions that can worsen without treatment.

The Trump administration has yet to officially approved a Medicaid work requirement. But research like this suggests that when and if they do, people with real physical and mental barriers to work will be the ones at risk of losing health coverage.

Quote of the Day

“What happened to Roy Moore is the scariest thing in the world.

That any of us could live a life of complete integrity, and have your name ruined forever. And then have your name ruined with false allegations.”

What Roy Moore's campaign can teach us about political psychology. I'm surely biased, but Vox's Brian Resnick is doing some fascinating work this year on why people believe what they do about politics in the age of Trump. His latest piece is a doozy: He went down to Alabama to find out why Roy Moore voters are sticking by their candidate in the face of credible accusations of sexual assault.

Kliff’s Notes

With research help from Caitlin Davis

Today's top news

  • “PhRMA sues to block Calif. drug transparency law”: “Drug companies are suing the state of California over a recently enacted law that would require manufacturers to give advance notice before significantly raising prices.” —Nathaniel Weixel, the Hill
  • “Deadline week crunch for health law sign-ups under Trump”: “The Trump administration came into office looking to dismantle Barack Obama’s health care law, but the Affordable Care Act survived. Now the administration is on the hook to deliver a smooth ending to sign-up season, with a crush of customers expected this week.” —Ricardo Alonso-Zaldivar, Associated Press

Analysis and longer reads

  • “Hospitals Are Merging to Face Off With Insurers”: “A fast-moving shakeout in the health-care sector has led to once-unorthodox deals across formerly distinct corners of the industry, as large insurers shift their business models amid pressure to bring down costs. That in turn has led hospitals to look for ways to preserve their revenues.” —Zachary Tracer, Bloomberg
  • “Prescription Drugs May Cost More With Insurance Than Without It”: “When insurers seek deals for generic drugs, they do so in batches, reaching agreements for groups of different drugs rather than getting the lowest price on every drug. As a result of these complicated layers of negotiation — which are not made public — different insurers end up paying different prices for individual drugs.” —Charles Ornstein and Katie Thomas, New York Times and ProPublica
  • “ACOs savings aren't driven by reduced hospitalizations”: “The net savings from Medicare's accountable care organizations weren't driven by reductions in hospitalizations despite the program's emphasis on tackling costly inpatient stays, a new study finds.” —Maria Castellucci, Modern Healthcare
  • "UNM braces for Medicare change": "University of New Mexico officials say a planned change to Medicare payments could have a devastating impact on the UNM Comprehensive Cancer Center, eliminating more than $9 million in annual revenue – or nearly 10 percent of its total budget." —Jessica Dyer, Albuquerque Journal

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