As Medicaid work requirements gain traction, experts propose ways to reduce potential harm

August 8, 2018, University of Michigan
Key recommendations from a University of Michigan Medicaid research team about Medicaid work requirement policies in states. Credit: University of Michigan

New Medicaid rules in several states mean low-income people will have to work, or prove they're too unhealthy to work, to receive health coverage. Other states want permission to require the same, which could affect millions of Americans living in or near poverty.

Before these requirements get into full gear, a team of University of Michigan researchers is offering specific recommendations to help states ensure that work requirements don't harm the of people enrolled in Medicaid.

The chance of such harm from losing Medicaid coverage forms the basis of a court case that has put Kentucky's Medicaid work requirement on hold and led to a public comment period that closes August 18.

The U-M team, which has studied Medicaid for years, published their recommendations in the New England Journal of Medicine. Their prior work on Michigan's Medicaid expansion showed that half of enrollees already work, and many others have health problems that limit their ability to work.

"We wanted to address the essential question: 'If we're going to have work requirements, then how can states implement them in the most humane way, so that the requirements focus on those who are more able to work and are less likely to experience worsening health if they lose coverage?'," asks John Z. Ayanian, M.D., M.P.P., lead author of the article and director of the U-M Institute for Healthcare Policy and Innovation. "We based our recommendations on the evidence we have about the current Medicaid expansion population. We hope state policymakers will take our recommendations into account as they seek to create reasonable, sustainable programs."

Ayanian and his co-authors are all general internal medicine physicians who provide primary care to patients at Michigan Medicine, U-M's academic medical center. Their recommendations focus in part on the new role that physicians would play in states that implement Medicaid work requirements.

The team recommends that states:

  • Focus on adults under age 50 who enrolled in Medicaid expansions. Compared to people over 50 and those under 50 whose health problem are serious enough to qualify them for traditional Medicaid, this population is less likely to suffer harm if the state bases their health insurance on their ability to work, or do another activity such as volunteering, attending school, undergoing addiction treatment or caring for a relative with a seriously illness or disability. That's because research has shown they are less likely to have chronic health conditions or limits on their everyday function that could get worse if they lose their health insurance because they don't meet a work requirement. The team notes that Arkansas, which implemented a Medicaid work requirement June 1, already follows this recommendation.
  • Give doctors clear guidance. While doctors already play a key role in some certifications related to their patients' disability status or ability to do certain jobs, Medicaid work requirements would ramp up that role to include many more patients. So, states should make it clear to physicians exactly what health conditions and functional limits will make someone exempt from a work requirement—or what limitations a person must have in order to require the level of caregiving that a family member could provide in order to meet their work requirement. In the latter case, the physician certifying a patient's level of disability or need for caregiving could affect the health insurance coverage for the patient's caregiver—someone not in their direct care. The new requirements may increase the workload for physicians and their staff appreciably.
  • Support work-related needs. Although the Medicaid system itself cannot pay using federal funds for services such as job training, help finding a job, or help getting to and from work or caring for children while a parent works, states that require work should connect Medicaid enrollees to such services, the team says. Such services would improve the odds that people covered by Medicaid will be able to find and keep jobs that will allow them to meet their state requirement, or even find a job that pays enough or provides health insurance benefits so that they no longer need Medicaid.
  • Make work reporting line up with today's work environment. As more workers have work patterns with hours that fluctuate week to week, have occasional gaps due to temporary jobs, or work that is concentrated in certain seasons, states should take this into account in their Medicaid reporting requirements, the team says. Requiring that participants report their work histories less frequently, covering a longer period of time, could smooth out these fluctuations and reduce the chance that a person who is making an effort to work will have to leave the Medicaid program.

Ayanian and co-authors Renuka Tipirneni, M.D., M.S., and Susan Goold, M.D., M.A., M.H.S.A., note that as work requirements become more widespread as part of ongoing or new Medicaid expansion programs, the details of implementation will become more important. All are faculty members in the Division of General Internal Medicine at the U-M Medical School, and members of IHPI.

"If the goal is to help people improve their economic standing in life and become self-sufficient, they'll need support to do so," says Ayanian, who also holds faculty appointments in the U-M Ford School of Public Policy and School of Public Health. "States should prevent potential harm that will arise if people with chronic conditions lose their Medicaid coverage, and therefore their access to health care providers and medications, especially if the economy changes."

Adds Goold, "If the goal is to provide a 'leg up' to economic self-sufficiency rather than a 'hand out,' providing through Medicaid is just one piece of providing such support. Child care, transportation, education and training, as well as health issues, present obstacles to self-sufficiency."

Explore further: Increased coverage in states with medicaid expansion

More information: New England Journal of Medicine (2018). DOI: 10.1056/NEJMp1806129

Related Stories

Increased coverage in states with medicaid expansion

July 23, 2018
(HealthDay)—Coverage rates and access to care are significantly higher in states with Medicaid expansion, compared with non-expansion states, according to a study published in the July issue of Health Affairs.

Medicaid work requirements and health savings accounts may impact people's coverage

June 20, 2018
Current experimental approaches in Medicaid programs—including requirements to pay premiums, contribute to health savings accounts, or to work—may lead to unintended consequences for patient coverage and access, such ...

Most enrolled in Michigan's Medicaid expansion already either work or can't work: study

December 11, 2017
Nearly half of the people who enrolled in Medicaid after it expanded in Michigan have jobs, a new study finds. Another 11 percent can't work, likely due to serious physical or mental health conditions.

Study finds Medicaid expansion boosts employment

July 19, 2018
Individuals with disabilities are significantly more likely to be employed in states that have expanded Medicaid coverage as part of the Affordable Care Act, new research from the University of Kansas has found. Similarly, ...

Medicaid expansion produces significant health benefits, study finds

June 5, 2018
The first peer-reviewed comprehensive analysis of the effects of Medicaid expansion paints a picture of significant improvements in various health outcomes consistent with the original goals of the Affordable Care Act, also ...

Trump allows US states work rules for Medicaid enrollees

January 11, 2018
Donald Trump's administration moved Thursday to let states require that able-bodied adults work in order to receive health care benefits through Medicaid, a pillar of the US social safety net.

Recommended for you

Receiving genetic information can change risk

December 11, 2018
Millions of people in the United States alone have submitted their DNA for analysis and received information that not only predicts their risk for disease but, it turns out, in some cases might also have influenced that risk, ...

Yes please to yoghurt and cheese: The new improved Mediterranean diet

December 11, 2018
Thousands of Australians can take heart as new research from the University of South Australia shows a dairy-enhanced Mediterranean diet will significantly increase health outcomes for those at risk of cardiovascular disease ...

Effect of oral alfacalcidol on clinical outcomes in patients without secondary hyperparathyroidism

December 11, 2018
Treatment with active vitamin D did not decrease cardiovascular events in kidney patients undergoing hemodialysis, according to a research group in Japan. They have reported their research results in the December 11 issue ...

Licence to Swill: James Bond's drinking over six decades

December 10, 2018
He may be licensed to kill but fictional British secret service agent James Bond has a severe alcohol use disorder, according to an analysis of his drinking behaviour published in the Medical Journal of Australia's Christmas ...

Obesity, risk of cognitive dysfunction? Consider high-intensity interval exercise

December 10, 2018
It's fast-paced, takes less time to do, and burns a lot of calories. High-intensity interval exercise is widely recognized as the most time-efficient and effective way to exercise. In a first-of-its-kind study, researchers ...

How to survive on 'Game of Thrones': Switch allegiances

December 9, 2018
Characters in the Game of Thrones TV series are more likely to die if they do not switch allegiance, and are male, according to an article published in the open access journal Injury Epidemiology.


Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.