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Liberals and conservatives have irreconcilable differences of policy and principle over the issue of Medicaid "work requirements." But their impact depends on how they are implemented and is likely to be very small — because most people on Medicaid who can work already are.

Expand chart
Data: Kaiser Family Foundation analysis of March 2016 Current Population Survey; Chart: Andrew Witherspoon / Axios

With Trumpcare dead for now, expect Republican governors to begin submitting waiver proposals to the Department of Health and Human Services to move their Medicaid programs in a more conservative direction. Medicaid "work requirements" are likely to be an element of many of those waiver requests, possibly from Republican-led states now looking to expand Medicaid under the Affordable Care Act.

During the Obama administration, HHS rejected mandatory work requirements as inconsistent with the purposes of the Medicaid statute, spurning requests from Arizona, Indiana, and Pennsylvania under a previous governor. Under the Trump presidency, HHS is expected to approve them.

Medicaid "work requirements" are not requirements to work in a literal sense. Generally, this is how states would define them:

  • Able-bodied beneficiaries — people who can work — would have to look for a job, participate in a job training program or go to school, or work full time or part time.
  • People who would be exempt: anyone who can document that they are too sick or disabled to work, have to take care of a sick child or family member, or do not have adequate child care.

Liberals find Medicaid work requirements repugnant because they believe that Medicaid beneficiaries want to work if they can, and that providing health coverage to people who cannot afford it is an obligation of any moral nation. Conservatives who favor work requirements see Medicaid coverage as another form of government welfare benefit, like cash assistance, requiring reciprocal obligations from beneficiaries, and a disincentive to work.

The reality, though, is that most Medicaid beneficiaries are working already, and the vast majority of those who are not working are likely to be exempted from all but the most draconian Medicaid work requirements when front-line caseworkers apply state rules.

As the chart shows:

  • 59% of all Medicaid beneficiaries who were not on Supplemental Security Income — the program for low-income people with disabilities — were working full time (41%) or part time (18%) in 2015.
  • That leaves 41% who were not working. Of those, the vast majority (89%) had reasons for not working, including that they were sick or had a disability (35%), were taking care of a family member (28%), or were in school (18%).
  • Another 8% said they could not find a job which, when documented, usually satisfies work requirements.
  • All told, just a tiny subset of Medicaid beneficiaries are-able bodied adults who do not have a reason for not working that would fail to pass muster with a state case worker.

Medicaid work requirements send signals conservatives like and liberals reject. As I learned a long time ago designing and implementing a leading welfare reform program as Commissioner of Human Services in New Jersey, the fight about policy and principle can get hot when it comes to work requirements, but their impact depends on how they are implemented.

With most beneficiaries working or with good reasons not to be, that impact will be small.

Drew Altman is president and CEO of the Kaiser Family Foundation in Menlo Park, Calif. and an Axios contributor.

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