EMILY GILL
The United States is an outlier among developed countries in its approach to medical care. This trajectory began after World War II, when similar countries were creating universal health coverage. Instead of making doctors public employees (Great Britian), developing public insurance that paid doctors (Canada), or providing basic insurance with the option of supplementary private plans (Australia), we tied health insurance to employment. Although Medicare covers all adults over 65, Medicaid originally covered only those already receiving cash assistance because their medical conditions prevented their employment, mainly the blind, the disabled, and single women with children. Although coverage gradually expanded, Medicaid was assumed to be for those who were vulnerable for reasons other than poverty. But the idea that medical coverage should somehow be tied to work started back in the 1940s.
After Obamacare passed in 2010, a few Republican states proposed adding a work requirement for Medicaid. These efforts were blocked, however, either by the courts or the Biden administration. President Trump’s large domestic policy bill passed in July requires that Medicaid enrollees prove that they are working, looking for work, or are unable to work. About 10 million people are slated to lose their coverage in 2026. House Speaker Mike Johnson said that the people losing coverage are perpetrating fraud and “cheating the system.” Medicaid spending will decline $325 billion over the next decade, and unfortunately, at least some of these funds will finance tax cuts for the wealthy.
Republicans and a number of Democrats support the new work requirements. Many people who pay for private insurance resent the fact that people who do not work have free health coverage. Nevertheless, imposing work requirements for Medicaid is a misguided policy. First, employers, not employees, make hiring decisions. Based on anticipated consumer demand, they may schedule employees for few hours or no hours some months. People should not be penalized for what they cannot control. Several years ago, Arkansas tried work requirements for Medicaid, removing 18,000 adults from the rolls in four months, but this did not increase employment.
Second, according to the Census Bureau’s current population survey, about 46% of Medicaid beneficiaries are either 65 or over or are children. Of those of working age, about half are working and a quarter have a disability that limits or prevents work. Another fifth will work within the next year or leave Medicaid within fifteen months. In sum, only 6% of the working-age enrollees are not involved in long-term work, meaning 3% of the total Medicaid population.
Third, people will lose coverage because they cannot keep up with the paperwork proving their monthly work hours. This has already been illustrated by beneficiaries required to recertify their Medicaid status when the COVID eligibility rules ended. Almost 70% of disenrollments resulted from procedural difficulties, not from ineligibility.
The central moral question here is whether everything that individuals receive should be earned, or whether it is wrong when some individuals get something for nothing. Health care services should be like fire and police services — we turn to them when something goes wrong, often catastrophically. Public education and public libraries are not rationed according to hours patrons have worked. All of these are public goods: we all benefit when all people are protected against fire and crime and are educated and healthy. People do not become more employable when they suffer from untreated medical conditions.
Political theorist Michael Walzer points out that during the Middle Ages in Europe, “the cure of souls was public, the cure of bodies private.” In most European countries now, the reverse is true. “Among medieval Christians, eternity was a socially recognized need; and every effort was made to see that it was widely and equally distributed,” with a church in each parish, regular services, and so forth. Developed countries manage to distribute health care widely. The United States should recognize the value in doing so also.
— Emily Gill is Caterpillar Professor of Political Science Emerita, Bradley University.