COMMENTARY

Is Medicaid Only for Those Who 'Deserve' It?

Arthur L. Caplan, PhD

Disclosures

May 18, 2017

Hello. I am Art Caplan. I teach medical ethics at the New York University (NYU) School of Medicine in New York City.

I am irritated today. Why? Because we keep getting proposals from Washington that suggest that people ought to work if they want to be eligible for Medicaid. What bothers me about this is that it is a reversion to 19th-century thinking, that the people who deserve healthcare are only those who earn it. This was the attitude when Charles Dickens wrote Oliver Twist, which was a bit biographical in that his own dad was hauled off to debtor's prison when the author was a child. He bemoaned the idea that only the "deserving" poor should get our aid.

Take a look at the Medicaid program: About half of the people enrolled in Medicaid are children, another large percentage are low-income elderly, and another have disabilities that make it impossible to work.[1] The number of people in the Medicaid program who are able-bodied and could work is probably less than 10% of those who get it. This is not to say that they are not looking for work; it is just that at the time that they become eligible, they do not have a job.

It seems to me that we have to reconcile ourselves to the idea that healthcare ought to be a right; it does not have to include everything, not all the bells and whistles, but it must include basic care. You cannot work unless you are healthy. Telling people that they cannot get into Medicaid unless they are working is a vicious cycle. It says: We are not going to give you the healthcare you may need to be healthy enough to get out there and get a job. In any event, if you are super-poor, if you have kids or elderly parents who rely on you, or siblings you need to take care of, perhaps that is why you are unable to work.

I do not want to means-test this issue, and I do not want a test that is mean. I do not want to be saying that only the "deserving" poor should get medical assistance. I still see basic healthcare as a right that we should give to everyone. We should figure out how to pay for it, levy taxes, figure out whether it is best provided by insurance. Not everyone will qualify for cosmetic surgery; not everyone goes to the spa; not everyone gets to travel to the faraway hospital. But surgery for broken bones and taking out your gallbladder, and making sure you can see, hear, chew, and walk, ought to be the right of every American because it is the only way to assure that, in a capitalist society, people can work, people can compete, and people can use their capacities and abilities to the fullest.

Let's not get mean about Medicaid; let's get sensible about it. Let's provide it so that people are able to work.

I am Art Caplan at the NYU School of Medicine. Thank you for watching.

Talking Points

Issues to Consider: Is Medicaid Only for Those Who "Deserve" It?

  • In the past 3 years, some states have proposed mandatory or voluntary work programs as part of their Section 1115 Medicaid expansion waiver applications.[2]

  • On March 14, 2017, in a letter to state governors, the Centers for Medicare & Medicaid Services indicated that they will use Section 1115 authority to approve provisions in the Medicaid program related to "training, employment, and independence."[2]

  • As of March 2017, Arizona, Indiana, Kentucky, and Pennsylvania had formally submitted waiver requests that would have required work as a condition of eligibility, none of which have been approved to date.[2]

  • Indiana, Montana, and New Hampshire have a voluntary work program referral separate from their Medicaid expansion waivers.[2]

  • Some healthcare professionals suggest that expansion of the Medicaid program to "able-bodied" adults disincentivizes work.

  • Some healthcare professionals are concerned that work requirements are ineffective in health coverage programs like Medicaid and could increase program costs if individuals are denied coverage for failure to comply and then seek emergency department care when they are sick.[2]

  • The Affordable Care Act's (ACA's) Medicaid expansion sought to expand health coverage regardless of whether a person with low income fits into a certain category of people.[2]

  • Many healthcare professionals contend that good health is a precondition to work, citing people who have encountered barriers to work as a result of dental needs, chronic pain, or other symptoms from untreated medical conditions and chronic illnesses.[2]

  • The Medicaid program covers more than 70 million Americans, or 1 in 5, including many with complex and costly needs for care. Historically, nonelderly adults without disabilities accounted for a small share (27%) of Medicaid enrollees.[3]

  • The ACA has expanded coverage to nonelderly adults with income up to 138% of the federal poverty level, or $16,394 for an individual in 2016.[3]

  • As of January 2017, a total of 32 states have implemented the ACA Medicaid expansion. By design, the expansion extended coverage to the working poor (both parents and childless adults), most of whom do not otherwise have access to affordable coverage.[3]

  • An analysis of the Michigan data also found that some Healthy Michigan Plan enrollees may seek employment or work longer hours if their health improves because of better access to care, thereby increasing the labor supply. Evidence regarding Medicaid expansions in 2014 suggests that they had no net effect on labor supply.[4]

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