Jonathan P. Baird

As the outlines of President Trump’s budget bill emerged into clearer focus, one fact became apparent. The bill has a shocker price tag. According to the Congressional Budget Office, over ten years, as many as 13.7 million Medicaid recipients will lose their health insurance. It will be the biggest loss of health care coverage ever sustained in American history.

The blow to health care this represents is nothing short of devastating. For poor and working people, this bill strips away what system of health care coverage has existed and replaces it with a far inferior model replete with new impediments. The new impediments are significant. They create barriers to access so that many fewer will qualify for care.

Adding work requirements to Medicaid is a key vehicle for the cuts and projected cost savings. Burdensome and repeated verification requirements are a proven recipe for shrinking rolls. While it may sound good to the uninitiated, there is a body of negative experience with states using such requirements. They create red tape to facilitate churning claimants and recipients off Medicaid.

New Hampshire, along with Arkansas, implemented work requirements in 2019 during Trump 1.0 but suspended the program and the federal court then halted it. There was confusion leading very large numbers to being disenrolled. Yet, those behind the new budget bill entirely ignore the history of how work requirements led to mass disenrollment.

The idea to make employment a precondition to Medicaid is bad public policy. Work requirements actually block access to medically necessary services that might enable work capacity. Medicaid is not a cash assistance welfare program. The purpose of Medicaid has been to furnish medical assistance, rehabilitation and other services that will help individuals attain and retain independence and self-care.

The budget bill plays on the stereotype of able-bodied, lazy people who are choosing not to work to get benefits but the stereotype gets it wrong. Nearly two out of three adult Medicaid enrollees aged 19-64 already work and most of the rest would be exempted for reasons like having a disability, caring for a family member or attending school.

Older adults receiving Medicaid will be particularly hard hit by the cuts. Around 70% of low income adults aged 50-64 live with chronic conditions and experience poor health. Under the budget bill, workers in all states up to age 65 will be subject to the work requirements. Experience has shown that exemptions commonly fail to work and end up excluding many who should remain eligible. It is a safe bet that millions who should be eligible will be locked out of coverage for extended time periods because of red tape..

The harm of the upcoming Medicaid cuts, starting at the end of 2026, is not well-understood. Not having health insurance literally kills. To avoid incurring costs, many will not go to the doctor or they will delay going. If they are suffering from cardiovascular illness, diabetes or cancer, delay could be life-threatening. People will not obtain the medication or treatment they need in a timely fashion.

Putting off care when conditions can be best-treated will lead to worse outcomes and higher costs later as often happens when an uninsured person lands in an emergency room. A new study by investigators at the Keck School of Medicine of USC, Boston University and the University of Amsterdam in the Netherlands, published in the Lancet, found that reduction in Medicaid coverage could lead to thousands of additional deaths among working-age Americans as well as a disastrous financial burden for hundreds of thousands.

The Lancet article found that Medicaid cuts have a ripple effect on patient’s children, their parents and seniors who depended on the patient for care. Families experienced increased stress when primary breadwinners were out of commission. Medical debt can pile up, especially on those who have complex health needs. Those in worse health or those contending with a disability often suffered income loss because of difficulty in maintaining continuous employment.

In the past, Medicaid has generally not required co-pays or any balance billing beyond the Medicaid payment rate. There was an understanding that low income people could not afford such costs. The budget bill would force some Medicaid recipients to pay more for coverage through premiums or other fees. Such payment is entirely ill-advised as people rely on Medicaid because they cannot afford more costs or any private insurance options. They lack the income. This will be creating another impediment to care.

I saw that some Republicans were citing former President Bill Clinton’s use of work requirements with welfare (TANF) to justify Medicaid work requirements. While they have been touted, Clinton’s work requirements ultimately failed and ruined the TANF program, dramatically reducing the number of enrollees. That program is now a shrunken shell of what it once was which is likely the same goal Republicans have for Medicaid. Reducing the size of the program using excessive paperwork and frequent verification requirements is their goal.

All this is done to line the pockets of the obscenely wealthy so they can receive their precious tax cut. It is about a gluttonous transfer of wealth upwards at the expense of the low income. What happened to the goal of universal health care and recognizing health as a human right? The budget bill moves the ball backwards down the field.