If enacted, these proposals would have significant repercussions for millions of struggling Americans. The nonpartisan Congressional Budget Office projects that by 2034, 16 million people could lose health insurance if Medicaid work mandates are widely implemented, Affordable Care Act (ACA) tax credits enacted under the American Rescue Plan Act are allowed to expire, and other policies relating to ACA enrollment become law. Additional proposals include cuts to the Supplemental Nutrition Assistance Program and raising the existing work requirement age limit for that program from 54 to 65.
The rhetoric supporting these measures draws from tired stereotypes casting low-income Americans as undeserving or lazy. This narrative ignores a key fact: Over 90 percent of adults on Medicaid already work or meet valid exemptions, such as disability, caregiving responsibilities or enrollment in school. Efforts to push the remaining 10 percent into work have repeatedly failed in states that tried to institute them, in many cases blocked by courts.
Nevertheless, proponents of work requirements continue to argue that they would save money and reduce the deficit. The argument goes something like this: Individuals who work would make too much to qualify for Medicaid, their employers would pick up health-care costs, and individuals and society would be better off. But there is no credible data that shows that work mandates save money; they increase administrative costs while reducing or eliminating coverage of those in need. In 2018, Arkansas became the first state to implement work rules under its Medicaid expansion program, only to disenroll 18,000 people before a federal judge halted the program. Researchers found no significant boost in total employment from Arkansas’ program during its brief existence.
Georgia currently stands alone as the only state enforcing a work requirement. Under Georgia Pathways to Coverage, its limited form of Medicaid expansion launched in July 2023, the state expected to enroll 60,000 low-income residents in the first year. Only about 4,200 signed up. According to reporting by ProPublica and The Current, a Georgia-based news organization, the program’s bureaucratic red tape — not laziness — has been the real barrier.
The impact is compounded by Georgia’s continued refusal to fully expand Medicaid under the Affordable Care Act. Georgia is one of 10 states that have refused expansion, even though doing so would provide coverage to those earning up to 138 percent of the federal poverty line and would mostly be paid for by federal subsidies.
Despite the experiences of Arkansas and Georgia — and continued efforts by other states to impose Medicaid work rules on their own — the current national debate too often suggests that only Democratic-leaning states, with their large low-income urban populations, would feel the effects. But that narrative misses the mark. Rural communities and red states stand to lose significantly as well. The Associated Press reports that rural hospitals in particular could face devastating losses if Medicaid patients suddenly become uninsured and unable to pay for emergency care.
The kinds of changes to social programs being debated in Washington and state capitals will hurt vulnerable people everywhere. A nation is judged by how it treats its most at-risk citizens. Since Medicaid’s creation in 1965 under President Lyndon Johnson’s Great Society agenda, and its expansion through the Affordable Care Act passed in 2010, these programs have helped millions gain basic access to health care. Public officials must make sure they continue to do just that.
Governing’s opinion columns reflect the views of their authors and not necessarily those of Governing’s editors or management.
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