Should adults who are able to work be required to do so to get taxpayer-provided health insurance? — could lead to major changes in the social safety net.
The federal-state Medicaid program for low-income and disabled people covers more than 70 million U.S. residents — about 1 in 5 — including an increasing number of working-age adults. In a break from past federal policy, the Health and Human Services Department under Secretary Tom Price has already notified governors it stands ready to approve state waivers for "meritorious" programs that encourage work.
Separately, an amendment to the still-stuck House GOP health care bill would allow individual states to require work or training for adults, with exceptions such as pregnant women, or parents of a disabled child.
Yet a surprising number of working-age adults with Medicaid are already employed. Nearly 60 percent work either full- or part-time, mainly for employers that don't offer health insurance, says the nonpartisan Kaiser Family Foundation. Most who are not working report reasons such as illness, caring for a family member, or going to school.
Geraldine Stewart, a Medicaid beneficiary from Charlotte, North Carolina, questioned the impact of a work requirement on older adults. Stewart was incapacitated by painful problems with her feet, now relieved by surgery covered under the program. In her early 60s, she was able to return to part-time work as a home health aide after treatment.
"To do work anywhere, I have to have my feet," said Stewart. "I really hope that they do not force anyone who has a medical condition to work to have to pay for those services. I don't think it's been researched properly."
The debate over work requirements for safety net programs isn't new. With Medicaid, it doesn't break neatly along liberal-conservative lines.
On the political right, some say the idea is flawed because a person who refuses to work will still be able to get free treatment by going to a hospital emergency room. Others say Medicaid was established by law as a health program, and work requirements would compromise that original mission.
"It's a policy that comes out of a misunderstanding of the situation facing low-income families," Jason Helgerson, head of New York's Medicaid program, said of work requirements. "People need health care to function in the work force. Threatening that, in my view, does not help in any meaningful way."
In a recent letter to governors, HHS Secretary Price and Seema Verma, the new head of Medicare and Medicaid, suggested that work itself can be good for health. "The best way to improve the long-term health of low-income Americans is to empower them with skills and employment," they wrote.
Liberals are relishing the contrast if Trump pursues tax cuts for the wealthy while putting the poor to work. "The Republican focus is backwards," said Senate Democratic leader Chuck Schumer of New York.
Work requirements are under discussion in a number of states, and the first test for the Trump administration could come on a pending waiver application by Kentucky. The proposal from Republican Gov. Matt Bevin would allow the state to suspend coverage for able-bodied adults who don't comply. Job training and caring for a disabled relative would count toward fulfilling the obligation. "Medically frail" people dealing with certain conditions, from substance abuse to cancer, would be exempt.
For Bevin, getting federal approval is key to continuing a Medicaid expansion launched by his Democratic predecessor to take advantage of then-President Barack Obama's health care law. Nationwide, the future of the expansion is uncertain with Republicans committed to rolling back Obama's law. Work requirements could entice GOP-led states to expand their programs and cover more low-income adults.
That may be more symbolism than real change, said Robert Rector, a social policy expert with the conservative Heritage Foundation.
"I consider it misleading to suggest you are going have a meaningful work requirement in a medical program, because that's the most difficult area to do it in," said Rector. "If an individual doesn't perform, and then they get sick, it's just not going to be enforced."
Advocacy groups representing the poor may go to court. "Medicaid is a medical assistance program," said Jane Perkins, legal director the National Health Law Program. "We do have a problem" with making work a condition of eligibility.
Others are worried that work requirements could become barriers for people down on their luck.
In small-town Paris, Tennessee, Medicaid beneficiary Mayela Stephenson said, "I wasn't afraid of work."
Now in her mid-50s, she worked factory jobs most of her life before becoming disabled due to nerve and bone problems. Even with her disability, Stephenson said she had to get legal help to force the state to grant her Medicaid.
Although she agrees that able-bodied people should work, Stephenson said she has concerns that those with health problems will get hurt.
"How would one measure someone's disability as to what degree that person would be able to work?" she asked. "It would have to be based on each individual's circumstance. You would have to go case-by-case, and how on earth will they do that?"
