As Congress considers cutting Medicaid to finance President Trump’s legislative agenda, one of the proposals that appears to have a great deal of support from Republicans is the imposition of a punitive work reporting requirement as a condition of Medicaid eligibility. I have long held the view that this approach is deeply flawed for a variety of reasons — including that there is no evidence that work reporting requirements actually support work but plenty of evidence that they cause people to lose health insurance. And implementation of this flawed approach costs taxpayers money to pay for IT consultants needed to set up complex and ineffective administrative structures.
This blog however, is going to focus on some additional reasons why a national mandate by Congress to implement such a policy would be incredibly harmful – specifically the burden on physicians and other clinicians should a Medicaid work reporting requirement be established by Congress as well as the fallacy that people with disabilities will be successfully exempted.
Proponents of work reporting requirements at the state and federal level typically argue that only those who are “able-bodied” will be subject to the possible loss of health insurance as a result of noncompliance with a work reporting requirement. So no need to worry, they claim, about those who may be receiving treatment for cancer, have a substance use disorder or suffer from other chronic conditions such as diabetes or hypertension. That is the rhetoric, but do Congressional work reporting requirement proposals actually ensure this?
To start, from the tenor of the Congressional discussion, one would expect that work reporting requirements would apply only to the Medicaid Affordable Care Act adult expansion group (known as Group VIII in the statute), but this is not how recently introduced work reporting requirement bills have been written as my colleague Andy Schneider points out. There are 14 million adults in Group VIII and another 18 million adults in “traditional” categories, so they would apply to a lot of people. Under either approach, we can confidently expect to see a list of “exempted” groups.
Let’s look closely at the text of H.R. 1279 whose lead sponsor is Rep. Aaron Bean (R-FL). We’ve been looking at this bill because it closely mirrors the text of a provision that passed the House in 2023, as Andy Schneider pointed out in his companion blog. The bill is broadly applicable to everyone who is 18 to 65[1] with a list of exemptions including being pregnant, having a dependent child, being a student etc. These are common exemptions when states pursue work reporting requirement Section 1115 waivers as well. There are two exemptions that I want to drill down on that relate to people with disabilities:
- (ii) physically or mentally unfit for employment, as determined by a physician or other medical professional; …
- (vii) participating in a drug or alcohol treatment and rehabilitation program (as defined in section 3(h) of the Food and Nutrition Act of 2008)
With respect to the first exemption, if Congress imposes a mandatory work reporting requirement, physicians, psychiatrists and other medical professionals around the country will find themselves in a very uncomfortable position with an untenable choice – either declare that their patient is “physically or mentally unfit for employment” or not – in which case the patient will be at risk for losing their health insurance. Physicians are not necessarily trained to make this assessment either – they would have to make a very consequential guess.
Presumably, states would automatically exempt some people, but if the Medicaid unwinding experience is any guide, confusion and poor communication will rule the day and many eligible people will lose health insurance. Leaving aside the ethical questions, are clinicians prepared for the flood of paperwork and questions coming their way? Will this cause them to spend less time with their patients (which is already a huge challenge in our health care system)? Will they be reimbursed at higher rates by managed care companies to compensate for their time?
An easy answer, proponents of work requirements might say, is to exclude those who have been declared disabled by the government already – those who are receiving Supplemental Security Income (SSI). But this is not actually what the current Republican bills say – and even if they did, this would not work for two reasons. Because two-thirds of people with disabilities enrolled in Medicaid do not receive SSI. And SSI income-eligibility standards in all but one state are also well below Medicaid adult expansion eligibility, which is 138 percent FPL.
The Trump Administration recently extended the public health emergency related to opioid use disorder. Yet the exemption for people with substance use disorders (which of course are not limited to people with opioid use disorder) is limited to those “participating in a drug and alcohol program”. According to data from the 2023 National Survey on Drug Use and Health, 85.4 percent of people in need of treatment did not receive it. Moreover, the definition cross-referenced here is decades old and appears to leave out private, for-profit treatment facilities, which constitute almost half of the current treatment facilities. (See p. 9 of the National Substance Use and Mental Health Services Survey). So this exemption is wholly inadequate.
Should such a policy be enacted, clinicians may be placed in the position of facing huge paperwork burdens, but more importantly forced to make decisions that have extraordinary and life-altering consequences for their patients. Clinicians would likely face this burden even in states that don’t want to impose this onerous and counter-productive policy mandated by Congress. Ultimately, it is likely impossible to design exemptions that would work for these populations: the range and diversity of health conditions of people with disabilities and/or mental health and substance use disorders is so broad that it is impossible to develop exemption criteria to identify them all.
The stakes are incredibly high. A new analysis by the Urban Institute of a work reporting requirement that applies only to the smaller Group VIII finds that between 4.6 million to 5.2 million people would lose coverage if implemented. Clinicians are likely not aware of what may be coming their way. And Congress is moving quickly – with Speaker Johnson announcing his intention to have a bill passed out of the House by Memorial Day. Real danger lies ahead for people with disabilities and substance use disorders who rely on health coverage to access the treatment they need to survive as Congress rushes to enact a large slate of tax cuts that will disproportionately benefit the wealthy.
[1] This is an incredibly inclusive age range meaning 65 year-olds would have to work even in they are Medicare and Social Security eligible but need Medicaid for cost-sharing help. Eighteen-year-olds – who are defined as children in the Medicaid statute – would as well. Exemptions by age will be another issue to keep an eye on when Congress reveals legislative language.
[Editor’s Note: This blog is part of a series on work reporting requirements.]