In Aesop’s fable “The Ant and the Grasshopper,” the diligent ant works all summer saving food for the winter, and the grasshopper idles away his summer singing and dancing. As winter approaches, the hungry grasshopper comes to the ant seeking help, but because of the grasshopper’s improvidence, the ant refuses.

By emphasizing the virtue of working hard and the vice of unduly burdening others, the allegory illuminates an important, if unspoken, motive behind adding work requirements to the Medicaid program. The controversial policy makes access to Medicaid contingent on participating in at least 20 hours per week of community engagement (eg, working, volunteering, or training). It holds able-bodied enrollees accountable for what they choose to do or not to do by rewarding the good choice (get a job, and keep Medicaid) and punishing the bad choice (do not get a job, and lose Medicaid). Indeed, personal responsibility for self-sufficiency tugs on a thread that runs deep in the United States.

There are 2 critical assumptions at the heart of the policy that merit greater examination. First, how accurately can we distinguish between the deserving and undeserving—the ant and the grasshopper? The study by Venkataramani and colleagues1 highlights the perils of this endeavor. Using 2018 administrative claims data for 100% of Kentucky’s Medicaid beneficiaries and original survey data, the authors estimated that, of the state’s 1 390 286 Medicaid beneficiaries, 48 427 (3.5%) do not meet the state’s community engagement requirements. These are people who would lose Medicaid unless they found a job or demonstrated positive steps in that direction. Depending on whom you ask, either 3.5% is too low to justify the bureaucratic and financial costs of instituting the policy, or 48 427 is justification enough to change how Medicaid eligibility is determined.

An even more fundamental point is, who are these 48 427 people? Venkataramani and colleagues1 begin to answer this question, as well. Administratively, they are defined by what they are not. They are not too young, they are not too old, they are not medically frail, they are not pregnant, and they are not in school.

Surveying these individuals, however, the authors found that 33.3% had activity-limiting health conditions in the last 30 days but did not meet the claims-based exemption for medical frailty, and 17.5% had jobs but did not meet the 20-hour threshold.1 Qualitative research could help us further understand who these individuals are and their barriers to work, but the survey findings alone suggest that a large portion of the 48 427 are simply false-negatives, incorrectly identified by the current administrative algorithm as not working but able-bodied and, hence, undeserving.

In comparison, previous estimates of those who do not meet the state’s work requirement have varied widely, from 28 000 individuals2 to 165 000 individuals.3 This variation underscores the importance of how narrowly or broadly the state defines exclusion and fulfillment. To be sure, the study by Venkataramani et al1 is likely the closest to Kentucky’s intended plans because it uses recent state data (rather than secondary data sets) and the state’s claim-based algorithm for determining medical frailty. Ultimately, any state’s attempt to distinguish between the deserving and undeserving is destined to be fraught with error.

The second assumption that merits attention is that poor personal choices mark the difference between having and not having a job. This assumption ignores the essential role that general economic conditions play in influencing employment. As one might expect, Medicaid enrollment increases during recessions and decreases during times of prosperity.4 What role does choice play?

To hold people accountable for their decisions, that choice must be “informed, voluntary, uncoerced, spontaneous, [and] deliberated….”5 Even more fundamentally, a fair choice implies the existence of at least 2 alternatives. A choice without alternatives is really no choice at all. In the case of work requirements, a fair choice hinges on jobs being available, particularly jobs commensurate with the education and skill level of those seeking employment.

Venkataramani and colleagues1 note that the unemployment and labor force participation rates in Kentucky vary widely depending on the designated workforce area. In recognition of this issue, the Kentucky Highlands Promise Zone, a region encompassing 8 rural counties with some of the highest unemployment rates in the state, ranging from 5.0% to 7.4%,6 is exempt from the community engagement requirements. The rationale offered by lawmakers can be summarized as, “When there are no jobs to be had, it doesn’t make sense to punish you for not working.”7 The presence of these exemptions forces proponents of the work requirements to acknowledge that having a job vs not having a job is not simply a matter of choice.

Whether the policy will, as its advocates have argued, improve the health of Medicaid’s enrollees, put them on a path toward self-sufficiency, and reduce overall spending on the program remains to be seen, but there is reason to be doubtful. The Medicaid work requirements failed scrutiny on 2 critical assumptions: that we can reliably distinguish between the deserving and undeserving, and that poor choices are the major barrier to work. Currently, the future of the policy remains uncertain. The Centers for Medicare & Medicaid Services has approved work requirements in 9 states and is actively considering the applications of 6 others.8 In March 2019, a federal judge ruled against Kentucky’s and Arkansas’s Medicaid work requirements.8 Two weeks later, however, the Trump administration moved to appeal the decision, so for the time being, the administration appears intent on moving forward with the policy.9

Short of abandoning work requirements altogether, as Maine has done,8 if the state of Kentucky is interested in helping the 48 427, it should identify the hurdles to work that these people face and target resources to lower these barriers rather than erect new ones. The results from Venkataramani and colleagues1 also show that, for each not-working but able-bodied individual (n = 48 427), there are approximately 2 others (n = 84 365) who must prove their worth, by either reporting their hours monthly or applying for a medical exemption via their physician or insurer. These are people who could lose health insurance because they are unaware of the rules, have trouble navigating all the red tape, or do not have reliable internet access to report their hours. Minimizing the burden of the work requirements on this group will be critical to mitigating the negative harms of the policy. This could take the form of broadening the automatic exemptions (such as lowering the age of exemption from 65 to 50 years, as is the case in Ohio, Wisconsin, and Arizona,2 because older adults tend to have more health and functional limitations), streamlining the reporting process (even putting the burden on employers rather than enrollees), and reducing the reporting interval from monthly to quarterly or yearly. More broadly, we must continue to support rigorous, independent evaluations of state policy like that performed by Venkataramani and colleagues, so that decisions are made less on allegory and more on evidence.

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Published: July 17, 2019. doi:10.1001/jamanetworkopen.2019.7178

Correction: This article was corrected on August 28, 2019, to remove an incorrect statement regarding Michigan’s work requirement exemption.

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Agarwal SD. JAMA Network Open.

Corresponding Author: Sumit D. Agarwal, MD, MPH, Division of General Internal Medicine, Brigham and Women’s Hospital, 1620 Tremont St, Boston, MA 02120 (sagarwal14@bwh.harvard.edu).

Conflict of Interest Disclosures: None reported.

Additional Contributions: Lisa S. Lehmann, MD, PhD (VA New England Healthcare System, Harvard Medical School, and Harvard T.H. Chan School of Public Health), provided uncompensated support in writing this commentary.