In the latest front of their war on the poor, Republicans in Congress are trotting out what could be one of their biggest health policy failures ever: Medicaid work requirements.
Republicans frame these mandates as a way to encourage people to work. But work requirements fail to increase employment, while only succeeding at tossing millions of people off Medicaid. And that’s exactly what Republicans in Congress are banking on.
Work requirements — or paperwork requirements, more accurately — are little more than a bureaucratic cudgel. They impose layers of complex red tape on Medicaid enrollees, forcing them to clear administrative hurdles and prove their employment status or that they qualify for an exemption (such as caregiving or attending school). The primary result is health care coverage being taken away from eligible Americans.
What happens when people lose their coverage? They forego care, fall into crippling debt, and may even die.
We know this because nearly everyone on Medicaid who can work already is. We also know this because states like Georgia and Arkansas have experimented with work requirements to disastrous results. In the latter state, for example, some 18,000 Arkansans lost coverage, even though researchers found “nearly everyone targeted by the policy already met the requirements.”
Republicans, however, are plowing ahead anyway. In March, experts at the Urban Institute estimated that between 4.6 million and 5.2 million adults ages 19 to 55 would have their health care ripped away due to paperwork hurdles from new work requirements.
But this is, of course, the GOP’s real goal: to keep as many people off Medicaid as possible. Indeed, consider why Republicans are proposing work requirements at all: to save federal dollars and help pay for trillions of dollars in tax cuts that overwhelmingly benefit the wealthiest Americans. Those savings can’t be realized if people keep their Medicaid coverage. They only accrue when coverage is lost.
What happens when people lose their coverage? They forego care, fall into crippling debt, and may even die. A 2017 study by Harvard health economist Benjamin D. Sommers that dug into the Affordable Care Act’s Medicaid expansion found that “one life [was] saved annually for every 239 to 316 adults gaining insurance.” Extrapolating from the Urban Institute’s coverage loss estimates, work requirements would lead to more than 15,400 avoidable deaths per year. Losing health care coverage because you couldn’t clear the red tape won’t make your cancer diagnosis disappear.
But that doesn’t matter to House Republicans. In fact, they want to make sure people who can’t meet their new Medicaid paperwork requirements cannot afford insurance at all. One especially cruel change buried in this new bill would make people who fail to satisfy Medicaid work requirements ineligible for any financial assistance to buy private coverage on their own through the ACA’s marketplaces. In other words, Republicans in Congress would effectively rip away the only affordable alternative to Medicaid, condemning millions of vulnerable Americans to go without coverage entirely.
The Republican bill will wreak extensive collateral damage. Work requirements are just one puzzle piece in Trump and Republicans’ larger plan to reduce government spending by kicking people off their health insurance. The nonpartisan Congressional Budget Office found that if you combine the effects of this bill with new rules Trump has proposed, and Congress’s refusal to extend the enhanced tax credits that keep ACA marketplace premium costs affordable, nearly 14 million more Americans will be uninsured by 2034. That’s a staggering number of folks who will no longer have financial protection against steep costs for prescriptions, doctor visits or hospital stays. To add to that suffering, for those fortunate enough to successfully navigate the new paperwork reporting requirements and keep their Medicaid, the House Republican plan would, for the first time, require states to impose out-of-pocket costs for accessing many health care services. In other words, they would force states to charge the poor to use their Medicaid coverage. Beyond causing millions of people to lose coverage and increasing health care costs for America’s most vulnerable families, the Republican bill will wreak extensive collateral damage. Researchers predict that hits from Medicaid work requirements could cost up to 450,000 jobs across the country and blow holes in state budgets. States with rural hospitals already on the brink of closure could face even deeper crises. What makes this especially hard to swallow is the “why” behind it all. Republicans in Congress aren’t proposing this as a measure of fiscal discipline. In the same bill, they propose more than $4 trillion in tax breaks that would disproportionately flow to the wealthiest Americans. All in all, the bill adds trillions of dollars to the national deficit, putting the United States on a significantly worse fiscal trajectory than it already is. They’re not doing this because they’re trying to be fiscally responsible. They’re doing it because they want to cut the Medicaid program by kicking off as many people as possible — and they’re hoping no one will notice.
Andrea Ducas
Andrea Ducas is the vice president of health policy at the Center for American Progress. 
