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The White House Council of Economic Advisers has an idea to make the country healthy and happy again: Give Medicaid beneficiaries a paycheck and health care. The one condition is that they can’t have the second without the first, and in so stipulating, the Trump administration is requiring people to work to receive medical care. Welfare advocates see two problems with tying Medicaid eligibility to “work requirements”: First, there’s often a reason people who are really sick don’t work—namely, that they face major barriers to earning a decent living. Second, most of those who can work already do—and they’re likely even sicker and poorer than before because of it. Ad Policy

In other words, the reason they’re on Medicaid isn’t to get a job, it’s to get health care. But somehow, the Trump administration thinks the government should treat being healthy more like a reward for employment rather than a basic right—as if, unless people “earn” the right to get chemotherapy, have a healthy pregnancy, or not die of asthma, they deserve to be ill.

A federal judge, however, demonstrated a better understanding of how Medicaid works than the White House last month, by blocking Kentucky’s work “incentives” plan for Medicaid—deeming the program “arbitrary and capricious,” after it was revealed that the plan could unfairly exclude thousands of people from benefits. But the Trump administration has disregarded the court order and continued to allow states to use special waiver provisions in Medicaid to condition benefits on beneficiaries’ proving that they had worked a certain number of hours a week. The Center on Budget and Policy Priorities (CBPP) notes that a similar program pending in Arkansas is now on track to push about 7,000 people out of the system for “failing” to work enough hours.

According to the White House’s rationale, the fact that many “non-disabled” adults are on welfare is a sign that they’re just not willing to work; the simple fact that many people who are non-disabled—and therefore considered “able-bodied”—are out of work, suggests a “decline in self-sufficiency,” according to the administration. So “Expanding work requirements…would improve self-sufficiency, with little risk of substantially reversing progress in addressing material hardship.”

In overhauling Medicaid, the administration is looking to programs like the old cash-assistance program, which was “reformed” under Clinton into a welfare-to-work program as a way of pushing people back into the workforce. But CBPP says that there are often very good reasons for people to be out of work, and forcing them to take jobs now could actually lead to a long-term loss of income and health. Under sweeping reforms to the Kentucky HEALTH program, maintaining Medicaid would require 80 hours per month of “community engagement,” and benefits could be cut if they earned incomes above the poverty level or were unable to meet the work requirement.

The federal court suspended the work requirement scheme, because of estimates that it might exclude some 95,000 people statewide from crucial health-care coverage. US District Judge James Boasberg noted a “stunning lack” of discussion of this risk; instead, politicians justified the reforms by arguing that work incentives would lead to “improved health,” and “quality of life,” and would “Empower people to seek employment and transition to commercial health coverage.” Boasberg concluded, “While those may all be worthy goals…there was a notable omission from the list.…would Kentucky HEALTH help or hurt states in ‘funding…medical services for the needy’?” The point of Medicaid, the nation’s keystone subsidized health-care program, isn’t to improve quality of life but to help people pay medical costs, period.

Of course, conservatives might see this kind of bureaucratic suicide as more of a feature than a bug: Imposing the work rules virtually guarantees that Medicaid rolls will decline—it’s arguably an orchestrated policy failure for politicians who actually want to eliminate the expansion of Medicaid under the Affordable Care Act. Current Issue View our current issue

The CBPP recently analyzed Medicaid records over the past 15 years and found that, contrary to the assumption that Medicaid beneficiaries often sponge off the system, the vast majority of “able-bodied” beneficiaries are either employed or actively seeking work. Among those with a high-school degree or less, nearly three-quarters had held jobs in the past year, or they opted not to for decent reasons: attending school, caring for a relative, or retiring early. Many worked, in fact, despite having a debilitating health condition.

Besides, for many, work did not pay off in the long term. Less-educated participants experienced relatively high rates of poverty; job tenure declined sharply within a few years, suggesting that work requirements offered few prospects for long-term career opportunity. The beneficiaries often worked in jobs like retail sales, nursing aides, cashiers and cooks: in other words, they got stuck in unsustainable jobs, which often leave people more vulnerable to crisis, and perhaps illness as well. Moreover, since these jobs tend to be “volatile and do not guarantee sufficient wages” to escape poverty, CBPP projects they will end up more, not less, dependent on safety net programs. Ultimately, “these requirements would put their food assistance benefits or health coverage at risk when they need that support most.”

And the more damaging impact, other than pushing people into bad jobs, could be unjustly cutting off people’s benefits because they cannot prove they either meet the work requirements or qualify for one of the narrow eligibility exemptions. Researchers found that “proving” they’ve worked the requisite number of hours will be extremely difficult because of “High levels of unemployment, job turnover and instability,” and volatile schedules.

According to CBPP analyst Judy Solomon, the Kentucky court ruling signals that the Medicaid population could be substantially destabilized by work requirements. Nonetheless, the administration is proceeding with rolling out similar programs in other states. Currently a similar work-requirement plan is launching in Arkansas, “although it raises issues similar to Kentucky. Similarly [Health and Human Services] could approve work requirements in other states despite the Kentucky decision. Arkansas and other state [plans] would have to be challenged in separate litigation.”

That the administration continues to flout the decision rather than step back from pushing more states to implement similar plans reveals just how little it cares about maintaining life-saving medical access for the poor. If people end up being condemned to deeper poverty and denied health care for “failing” to work enough hours, conservatives won’t see that as a failure of the program but as a sign of its success.