Commentary Law and Policy

Work Requirements Are Bad for Women’s Health

Priscilla Huang & Fabiola Carrion

Work requirements are unnecessary, burdensome, stigmatizing, and harmful to women and their families.

Medicaid is an important lifeline for women. The majority of adults enrolled in it—25 million individuals—are women. This critical program provides affordable health care coverage—including coverage for a range of reproductive health services—for a disproportionate share of women of color, women with low incomes, women with disabilities, single mothers, and women from other underserved populations.

Unfortunately, the Centers for Medicare & Medicaid Services (CMS) at the U.S. Department of Health and Human Services (HHS) is putting millions of women at risk of losing their health coverage with its latest move to dramatically undermine Medicaid as we know it. On January 11, CMS sent a letter to state Medicaid directors announcing a new policy encouraging states to apply “work and community engagement” requirements to some Medicaid recipients. Those subject to the requirement would have to show proof that they work, have looked for work, volunteer, go to school, or participate in a job-training program in order to receive benefits.

The next day, CMS approved an application from Kentucky to impose a mandatory 80-hour-per-month work requirement on current and future Medicaid enrollees. In early February, CMS approved an extension of Indiana’s troubled Medicaid waiver project, which will now also include work requirements. And on Monday, CMS approved a waiver for Arkansas that will allow the state to impose work requirements. CMS’ approvals were unprecedented; the previous administration had rejected state waiver applications to impose similar work requirements.

Work requirements are unnecessary, burdensome, stigmatizing, and harmful to women and their families. Most women on Medicaid already have jobs, and among mothers, the percentage of working women on Medicaid is even higher. Only about one in five adult enrollees in Medicaid live in a household without a working person. The vast majority of enrollees who are not working have a disability or are retired, in school, or taking care of relatives.

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Advocates believe that Kentucky’s waiver approval is illegal, and they are joining with Medicaid enrollees to fight back. On January 24, the National Health Law Program, along with the Southern Poverty Law Center and Kentucky Equal Justice Center, filed a federal lawsuit against HHS and CMS to challenge approval of Kentucky’s waiver application. (The authors of this piece work at the National Health Law Program.)

The plaintiffs are individuals who obtain their health care through Medicaid in Kentucky and will suffer serious harm under the state’s waivers. Eight of the 15 named plaintiffs are of reproductive age; they include married couples, college students, a musician, a custodian, a housekeeper, a pastor, a bank teller, and an auto repair person.

Among them is L.B., a 20-year-old woman with a number of medical conditions that require ongoing treatment, including mental health care. L.B. seeks to return to college after her health status becomes more stable.

The lawsuit claims Kentucky’s work requirements violate the Administrative Procedure Act, the Social Security Act, and the U.S. Constitution. By Kentucky’s own estimate, the waiver project will lead to nearly 100,000 fewer people enrolled in Medicaid.

The rhetoric used by HHS and state officials seeking to promote work requirements shows that these proposals are an insidious attempt to reduce Medicaid enrollment by playing on stereotypes that cast people who receive publicly funded services as “lazy” and “undeserving.”

In a recent television interview on PBS NewsHour, Kentucky Governor Matt Bevin (R) shared his opinion about “able-bodied” adults on Medicaid: “Why should somebody have to go to work every day and pay taxes to provide something to someone who could do the same thing, but chooses not to? That’s very un-American.” In the same interview, Bevin said, “The key is to have [Medicaid enrollees] engaged in their communities, because it is through that engagement that people have healthier outcomes.”

Gov. Bevin has it exactly backwards. If allowed to stand, these approvals would lead to terrible outcomes. Requiring work as a condition of Medicaid eligibility would cause gaps in coverage that would ruin the continuity of care necessary to ensure that individuals with chronic conditions maintain their health. Work requirements would also interfere with efficient care management.

Efforts to impose work requirements on people who receive food stamps or cash assistance like Temporary Assistance for Needy Families (TANF) have made the results of work requirements clear: Hundreds of thousands of eligible individuals who could not meet the complex documentation requirements have lost benefits. Several studies have found that TANF participants with physical and mental health issues are more likely to be sanctioned for not completing work requirements.

Moreover, the federal government’s association between work and health fails to account for the nuances in play, like quality of work. Studies show that unemployed individuals who begin work in poor quality—low-wage, low-status—jobs have poorer mental health than unemployed individuals.

On paper, the approvals for Kentucky and Indiana and the proposals in other states include exceptions for certain populations, including pregnant women, primary caretakers of dependents or people with disabilities, and students. Beyond the questionable legality of the work requirements, the reality is that these exceptions are unworkable.

For example, low-income women, particularly women of color, are more likely to be employed as domestic workers or in other informal job settings where there are no timesheets, pay stubs, or other forms of documentation to show their employment status. People on Medicaid already have low incomes and struggle to find work. Women of color—particularly Black and Latina women—are more likely to be unemployed and have longer periods of unemployment compared to white women.

Work requirements target everyone, not only people without jobs or caretaking responsibilities. The hidden victims of work requirements will include the overwhelming majority of women and other Medicaid enrollees who already work, care for family members, or are exempt, but will lose Medicaid because they are unable to navigate the burdensome paperwork and administrative complexities needed to prove their status.

Editor’s note: Gov. Bevin has filed a countersuit in response to the suit mentioned in this piece. 

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