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The striking evidence that Medicaid expansion can help single moms get jobs, briefly explained

Medicaid might actually help, not hurt, people looking for work. Here’s more proof.

Mainers for Health Care rally outside the State House prior to Gov. Paul LePage’s State of the State address, Tuesday, Feb. 13, 2018, in Augusta, Maine.
New evidence suggests Medicaid expansion, advocated for here by protesters in Maine, helps young moms find work.
Robert F. Bukaty/AP
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.

Buried in this fascinating New York Times report on single mothers surging into the US workforce is a whoa-if-true finding: Medicaid expansion might be helping young moms get work.

Here is the key paragraph from Ernie Tedeschi, a former Obama Treasury economist, and the Times’s Claire Cain Miller (emphasis mine):

There’s also some evidence, though not conclusive, that the expansion of Medicaid under the Affordable Care Act might have increased employment, particularly for people with disabilities. Young single mothers’ participation increased four percentage points more in states that expanded Medicaid in 2014 versus those that didn’t.

This is not a slam dunk, as Tedeschi explained to me. Medicaid expansion isn’t a perfectly randomized experiment — Democratic-led states largely expanded and it was mostly Republican states that didn’t. If the Democratic states (their urban areas particularly) have simply seen a strong economic recovery since the recession, that could explain such a finding without having to give credit to the expansion. The timing also seems a little off: Medicaid expansion started in 2014, the shift in single moms’ work patterns showed up in 2016. We should be cautious about overreading one data point.

But it could very well be that Medicaid expansion has helped young mothers get and hold onto employment. There would be two likely reasons, Tedeschi said: Mothers can make more money while still keeping their Medicaid benefits (whereas a lower Medicaid eligibility might discourage them from working in order to maintain coverage) and they can afford to take a job with no or subpar health insurance because Medicaid is covering them.

“I think the story here is most likely the hot labor market. But what nags me is that the turnaround in single mother [labor force participation rate] was very sudden, not gradual,” Tedeschi said. “Such a sudden turnaround is consistent with a change in public policy. I’d say the two leading candidates on the policy front are the ACA and state/local minimum wages.”

If true, it would be yet another blow to the Trump administration’s theory of the case, that Medicaid benefits can discourage people from working and therefore work requirements are needed to keep recipients incentivized to work. Trump officials have approved the first-ever Medicaid work requirements, despite evidence most Medicaid recipients either already work or wouldn’t be expected to.

This fight has raised a foundational question: Should Medicaid benefits be conditioned on work? The administration has run into trouble with the courts who believe they haven’t justified such a requirement, and findings like this go even further, by suggesting that making it harder for people to get Medicaid might actually harm their economic outlook.

The evidence that Medicaid work requirements could hurt working people, explained

As we’ve covered before, many people on Medicaid — those with federally qualifying disabilities, the elderly, children, pregnant women — would not be subject to these work requirements. The rest of them are generally already working: the Center for Budget and Policy Priorities reported last April, using census data, that two-thirds of people potentially subject to a work requirement were working and 70 percent of those worked 1,000 hours over a year, which comes out to 80 hours a month, Kentucky’s threshold for meeting its work requirement.

But just because you work enough in the aggregate doesn’t mean you work enough on a month-by-month basis to satisfy a Medicaid work requirement. CBPP found that nearly half of people (46 percent) who could be subject to a work requirement and were working had at least one month when they failed to clear Kentucky’s 80-hour bar.


A quick note on the methodology: CBPP had to use 2012 to 2013 census data to track month-by-month variations in income, but when it applied more general 2016 data, it found similar trends. You should read the report for a closer look at how it came up with the findings.

Lower-wage jobs tend to be more volatile, with fewer regular hours. Top industries for people who are likely to face a work requirement are food services, retail, and construction, according to CBPP — jobs that can be subject to seasonal and other shift changes.

Seven in 10 food service workers report that they work irregular hours, according to CBPP; 63 percent of retail workers said the same, along with 54 percent of construction workers. All three industries have above-average rates of people quitting or being laid off; retail and food services have some of the shortest average job tenures.

“Approved and pending state work requirement policies are based on the assumption that people who want to work can find steady employment at regular hours,” the CBPP authors wrote. “This assumption is out of step with the realities of the low-wage labor market.”

The other problem with Medicaid work requirements, CBPP noted, is the paperwork required to satisfy them. Working people who are doing what is asked of them under these requirements could still lose coverage if they fail to file the proper paperwork or if the state mismanages the forms they do file.

Even if states try to simplify the requirements — by putting the forms online, perhaps — CBPP noted that 19 percent of Kentucky Medicaid enrollees who could be subject to a work requirement don’t have internet access and 42 percent don’t have access to broadband internet. These are people who will struggle to clear such bureaucratic hurdles.

The data cited in this week’s Times report underlines the perversity: not only could Medicaid work requirements hurt working people, but Medicaid expansion alone — opposed by the Trump administration and Republican state officials, leaving more than 1 million people in non-expansion states without coverage — might actually do a better job than a work requirement.