Work hour requirements to get and keep Medicaid coverage are proposed or are now required in multiple states under the encouragement of the Trump Administration. Arkansas, Kentucky, and Indiana all have received approval for Medicaid waivers containing work requirements. Even states that haven’t expanded Medicaid, where covered adults are largely either elderly, disabled, or parents of dependent children, are proposing Medicaid work requirements.
While there are many variations in details, so far these work compliance rules require a minimum number of hours be worked each week – usually 20 (or 80 hours/month) – in order to qualify for Medicaid. And not meeting those hourly targets may mean not just losing Medicaid for that particular month but being locked out of reapplying for Medicaid for multiple months thereafter.
Unfortunately, largely missing from the current Medicaid work requirement discussion is acknowledgement of how the structure of many jobs has changed over the last two decades for America’s lower-wage workforce and their families and how these changes can make these new strict Medicaid hourly work requirements difficult or impossible to meet.
Traditionally, regardless of wage scale, a full-time or part-time job required a relatively stable number of working hours per week. This gave some idea of working hours and income for a family, thus providing more certainty and structure for budgeting, childcare, transportation and similar arrangements. However, in 2018, this certainty is now the exception rather than the rule for low-wage workers. Multiple surveys report enormous variability in the weekly incomes and number of hours worked among low-wage employees. Seasonal variability, statistical predictions of consumer habits, and a new willingness among corporations to significantly juggle the number of hours an employee works weekly and even daily all combine to make the idea of a stable number of hours worked per week part of a bygone era for many employees and their families.
For example, data from a large multi-state survey of workers in jobs like cashiers, baggage handlers, hotel housekeepers, cooks and bank tellers tells a sobering story in a widely-quoted paper by SJ Lambert:
“In this study not one employer guaranteed a minimum number of hours for employees in hourly jobs – full-time or part-time…. Although full-time jobs still enjoy the reputation of providing workers a stable number of hours per week, the employers studied did not guarantee full-time workers full-time hours. For example, workers in full- time positions in airline catering companies were regularly sent home when flights were cancelled or delayed, and at least some housekeepers, food service workers, and sales associates in full-time jobs were not scheduled for full-time hours some weeks.” (1214-15)
This lack of certainty about work hours holds true across a range of settings. Researchers Nantiya Ruan and Nancy Reichman compared the disadvantages experienced by lower-wage workers with higher-wage workers and characterize these changes for the American workforce as “hours equity” as compared to “pay equity.” For example, workers in multiple types of low-wage jobs not only lack control over the number of hours they work each week but also “their starting and stopping times; hours assigned with no advance notice; and fluctuations in hours from week to week.” These changes hit parents and families especially hard. In a recent survey of working mothers in restaurant and food service jobs, nearly 50% reported an unpredictable schedule with many saying they had weekly changes and some even reporting daily changes. Many restaurants simply call in workers when they need them and leave them at home if business tapers off.
Similar worker surveys note this type of just-in-time scheduling is becoming a common practice in the service sector and hourly wage industries. Not being able to “get enough hours” makes for not only income instability but also can threaten qualification even if an employer provides a health insurance benefit. A recent University of Chicago study found that 90 percent of food service workers and 87 percent of retail workers reported substantial swings in their work hours from month to month. Unsurprisingly, now in states with a Medicaid work requirement this same instability now also threatens Medicaid eligibility.
Overall, the lowest income workers have the most irregular work schedules, with employees routinely reporting significant spikes and dips in their incomes due to irregular work, the seasonality of employment or a short period of unemployment. A look at the United States Department of Labor’s list of the lowest-wage jobs in America makes clear the types of jobs impacted by these work changes. Food preparation and service routinely rank the lowest in pay along with grocery store cashiers, dishwashers, childcare providers and hotel workers. And these lower income workers are much more likely to work for companies that do not provide health coverage to their workers.
As more states propose work hour requirements for Medicaid, policymakers must break out of the old paradigm that equates full or part-time employment with a steady schedule and constant work. Hourly Medicaid work requirements make little sense when confronted with the constantly shifting schedules and seasonal nature of many of the jobs filled by lower-income Americans. Instead, a focus on creating better jobs, improving worker protections, and providing better work and family supports – especially for parents dealing with child care expenses and school schedules – would be a smarter way to help people rise out of poverty.
