Editorial - Do Poor People Have a Right to Health Care?

The 16 Kentuckians who recently won a lawsuit challenging the legality of Medicaid work requirements include a law student with a rare heart condition, a mortician with diabetes, a mother of four with congenital hip dysplasia and a housekeeper with rheumatoid arthritis. It’s a mixed bunch, united by two grim facts: They live at or below the federal poverty level, and they’re caught in the cross hairs of a debate over what society owes its neediest members.

Their lawsuit argued that insisting that people work a certain number of hours a month in order to receive Medicaid benefits, like other requirements the state was planning to demand, is illegal because it runs counter to Medicaid’s purpose — to ensure that low-income people have access to decent care. The lawsuit also contended that such requirements would imperil the plaintiffs’ health by depriving them of the only medical insurance they could afford. The new rules, which would have stripped recipients of their benefits if they failed to meet monthly hours-worked quotas and strict reporting standards, were simply oblivious to the realities of low-wage living in Kentucky, and America in general.

On June 29, two days before those requirements were to take effect, a District Court judge ruled decisively for the plaintiffs, calling the Department of Health and Human Services “capricious” for approving Kentucky’s plan at the beginning of the year and lambasting Secretary Alex Azar for failing to consider the impact the measures would have on those in need. “The record shows that 95,000 people would lose Medicaid coverage,” Judge James Boasberg wrote in his decision. “And yet the Secretary paid no attention to that deprivation.”

Those statements are but the latest salvo in a protracted national reckoning over Medicaid, a program that has been in place for more than half a century and now insures one in five Americans, or roughly 74 million people. In January, the federal government announced that it would reverse decades of precedent and allow states to tie Medicaid coverage to work requirements. The move is part of a wider conservative-led campaign to restrict the number of people who benefit from social safety-net programs. It also reflects persistent national ambivalence over the question of whether health care is a human right or an earned privilege — and, if the latter, how “earned” should be defined.

Nearly a dozen other states are planning to put into effect programs like the one now blocked in Kentucky. The future of those initiatives is uncertain. As the Kentucky ruling makes plain, the arguments underpinning them are fatally flawed.

For instance, proponents say that work requirements fulfill the edicts of Medicaid because gainful employment is key to healthy living — higher earnings have been tied to longer life spans, and unemployment to shorter ones. That correlation is valid, but backward: Health is a prerequisite to employment, not the other way around. Medical problems are a common cause of job loss among the poor, because low-wage jobs offer few accommodations or protections for workers who become suddenly or chronically ill. Likewise, the argument that work requirements will help contain costs and keep Medicaid afloat seems fair enough on its face. States across the country are facing real strain as they try to rein in health care costs in general, and cover their share of Medicaid expansion in particular. But work requirement programs will not be cheap. Kentucky officials say theirs would save the state $2.4 billion in the first five years, but nearly half of that savings would be spent ensuring that the state’s million-plus Medicaid recipients comply with the new rules.

Even the basic ideological argument for work requirements — that people should earn their government benefits — collapses under scrutiny. Numerous analyses have indicated that a clear majority of Medicaid recipients who can work already do work. Of the 9.8 million working-age Medicaid recipients who are not employed, the vast majority have physical limitations or provide full-time care to young or elderly family members; just 588,000 of them are able to hold jobs but are currently unemployed, according to a 2017 report. And most of those are actively looking for work.

Surely H.H.S. officials have seen this data.

They must also be familiar with the evidence indicating that punitive work requirements are ineffective. During welfare reform under Presidents Ronald Reagan and Bill Clinton, similar edicts disrupted people’s benefits without improving their employment prospects. In the Trump era, it has been repeatedly estimated that more working people would be culled from Medicaid’s rosters over paperwork violations than nonworking people for failing to find jobs. And both state and federal health officials may have heard that at least one state has found a way to help Medicaid recipients secure decent jobs without threatening their health insurance. In 2015, Montana implemented a bipartisan, state-funded employment initiative that offers Medicaid recipients a range of services, including career counseling, on-the-job training and tuition assistance. The program is voluntary — people can sign up when they enroll in Medicaid — and it’s paired with targeted outreach so that those who stand to benefit most from the program are aware of their options. So far, more than 22,000 Montanans have participated, and employment among nondisabled Medicaid recipients is up 9 percent in the state.

Given all this, it would seem that the Trump administration’s push to enact work requirements is aimed not at improving health, or even at cutting costs — there are more effective ways to do both — but rather at stigmatizing Medicaid, a program that has become less maligned in recent years, as more Americans have become insured under it. In one 2017 poll, 74 percent of respondents said they had a favorable view of Medicaid.

But while most Americans agree that poor people should have health insurance, they also believe that people of all income levels should earn their benefits — the same poll from last year found that 70 percent of respondents supported Medicaid work requirements. That paradox, of increasing support for Medicaid amid lingering suspicion toward Medicaid recipients, underscores persistent questions about how Americans view those in need. With advocacy groups vowing to file challenges similar to the one that prevailed in Kentucky, and with the state’s governor, Matt Bevin, saying he will exhaust every appeal and potentially end his state’s Medicaid expansion program altogether, those questions are almost certainly headed to the Supreme Court. Hopefully the justices, despite the high court’s impending rightward lurch, see through the conservative myths about Medicaid and do right by the program’s recipients.

A country’s deepest values are reflected in how it treats its most vulnerable citizens. So as officials consider the future of Medicaid, they must ask themselves: Is this how America is going to be?